What is BPPV repositioning

Modifications of the Epley (canalith repositioning) maneuver for posterior canal benign paroxysmal positional vertigo (BPPV)

BACKGROUND: Benign paroxsymal positional vertigo (BPPV) is a syndrome that is associated with short-lived episodes of vertigo with rapid changes in head position. It is a common cause of dizziness presenting to primary health care and specialist otorhinolaryngology (ENT) clinics. BPPV of the posterior canal is a specific type of BPPV for which the Epley (canalith repositioning) maneuver is a reviewed treatment. A number of modifications of the Epley maneuver are used in clinical practice, including post-Epley vestibular exercises and post-Epley postural restrictions. OBJECTIVES: To determine whether the various modifications of the Epley maneuver for posterior canal BPPV improve its effectiveness in clinical practice. Search Methods: We searched the Cochrane Group ENT Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE; CINAHL, Web of Science, BIOSIS Previews, Cambridge Scientific Abstracts; ICTRP and additional sources for the published and unpublished studies. The search date was December 15, 2011. Selection criteria Randomized controlled trials of changes in the Epley maneuver compared to a standard Epley maneuver were selected as controls in adults with posterior canal BPPV diagnosed with a positive test-Dix-Hallpike. Targeted modifications were sought: application of vibrations / oscillations to the mastoid region, vestibular rehabilitation exercises, further steps in the Epley maneuver and follow-up treatment instructions regarding restriction of freedom of movement. Data collection and analysis: two authors independently selected studies from the search results and the third author checked and corrected all inconsistencies. Two authors independently extracted the data from the studies using standardized data forms. All authors independently assessed the exams for risk of bias. Main Results The review comprised 11 studies with a total of 855 participants. A total of nine studies used post-Epley postural impairment restrictions as their modification of the Epley maneuver. There was no evidence of a difference in post-treatment outcomes for vertigo intensity or subjective assessment of improvement in individual or pooled data. All nine studies included converting from a positive to a negative Dix-Hallpike test as a result measure. The pooled data identified a significant difference from adding the posture restrictions in the frequency of the Dix-Hallpike conversion when compared to the Epley maneuver alone. In the experimental group, 88.7% (220 of 248) patients versus 78.2% (219 of 280) in the control group converted from a positive to negative Dix-Hallpike test (risk ratio (RR) 1.13, 95% confidence interval (CI) 1.05 to 1.22, p = 0.002). No serious side effects were reported, however three studies reported minor complications such as neck stiffness, horizontal BPPV, dizziness, and imbalance in some patients. There was no evidence of any benefit from mastoid oscillation during the Epley maneuver, or from additional steps applied in the Epley maneuver. No side effects were reported. AUTHORS 'CONCLUSIONS: There is evidence showing a statistically significant effect of post-Epley postural restraints compared to the Epley maneuvers alone. However, it is important to note that this statistically significant effect only cancels out a small improvement in the effectiveness of the treatment. An Epley maneuver alone is effective in just under 80% of patients with typical BPPV. The additional intervention of postural restrictions has a number needed to treat (NNT) of 10. The addition of postural restrictions neither cites harm to most patients, does not represent a major disadvantage, and can be routinely discussed and advised. Specific patients who experience discomfort due to wearing a neck brace and inconvenience in sleeping upright can be treated with the Epley maneuver alone and still expect to be cured in most cases. There is insufficient evidence to support the routine application of mastoid oscillation during the Epley maneuver, or additional steps in an "augmented" Epley maneuver. Neither the treatment is associated with negative consequences. Further studies should employ a rigorous randomization technique, blinded outcome assessment, a follow-up Dix-Hallpike test as outcome measure, and longer-term patient follow-up.

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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First added on: Apr 21, 2012