title: Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV).
abstract: BACKGROUND
  Benign paroxsymal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo associated with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology (ENT) clinics. BPPV of the posterior canal is a specific type of BPPV for which the Epley (canalith repositioning) manoeuvre is a verified treatment. A range of modifications of the Epley manoeuvre are used in clinical practice, including post-Epley vestibular exercises and post-Epley postural restrictions.
  
  
  OBJECTIVE
  To assess whether the various modifications of the Epley manoeuvre for posterior canal BPPV enhance its efficacy in clinical practice.
  
  
  METHODS
  We searched the Cochrane ENT Group 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CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 15 December 2011.
  
  
  METHODS
  Randomised controlled trials of modifications of the Epley manoeuvre versus a standard Epley manoeuvre as a control in adults with posterior canal BPPV diagnosed with a positive Dix-Hallpike test. Specific modifications sought were: application of vibration/oscillation to the mastoid region, vestibular rehabilitation exercises, additional steps in the Epley manoeuvre and post-treatment instructions relating to movement restriction.
  
  
  METHODS
  Two authors independently selected studies from the search results and the third author reviewed and resolved any disagreement. Two authors independently extracted data from the studies using standardised data forms. All authors independently assessed the trials for risk of bias.
  
  
  RESULTS
  The review includes 11 trials involving 855 participants. A total of nine studies used post-Epley postural restrictions as their modification of the Epley manoeuvre. There was no evidence of a difference in the results for post-treatment vertigo intensity or subjective assessment of improvement in individual or pooled data. All nine trials included the conversion of a positive to a negative Dix-Hallpike test as an outcome measure. Pooled data identified a significant difference from the addition of postural restrictions in the frequency of Dix-Hallpike conversion when compared to the Epley manoeuvre alone. In the experimental group 88.7% (220 out of 248) patients versus 78.2% (219 out 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 adverse effects were reported, however three studies reported minor complications such as neck stiffness, horizontal BPPV, dizziness and disequilibrium in some patients.There was no evidence of benefit of mastoid oscillation applied during the Epley manoeuvre, or of additional steps in the Epley manoeuvre. No adverse effects were reported.
  
  
  CONCLUSIONS
  There is evidence supporting a statistically significant effect of post-Epley postural restrictions in comparison to the Epley manoeuvre alone. However, it important to note that this statistically significant effect only highlights a small improvement in treatment efficacy. An Epley manoeuvre 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 does not expose the majority of patients to risk of harm, does not pose a major inconvenience, and can be routinely discussed and advised. Specific patients who experience discomfort due to wearing a cervical collar and inconvenience in sleeping upright may be treated with the Epley manoeuvre alone and still expect to be cured in most instances.There is insufficient evidence to support the routine application of mastoid oscillation during the Epley manoeuvre, or additional steps in an 'augmented' Epley manoeuvre. Neither treatment is associated with adverse outcomes. Further studies should employ a rigorous randomisation technique, blinded outcome assessment, a post-treatment Dix-Hallpike test as an outcome measure and longer-term follow-up of patients.
authors.affiliation: Peninsula College of Medicine and Dentistry, Royal Devon & Exeter Hospital, Exeter, UK.
authors.forename: William T
authors.initials: WT
authors.lastname: Hunt
authors.forename: Eleanor F
authors.initials: EF
authors.lastname: Zimmermann
authors.forename: Malcolm P
authors.initials: MP
authors.lastname: Hilton
mesh_terms: D065635:Benign Paroxysmal Positional Vertigo; D005081:Exercise Therapy / Q000379:methods; D006801:Humans; D007103:Immobilization / Q000295:instrumentation / Q000379:methods; D056888:Patient Positioning / Q000379:methods*; D011187:Posture / Q000502:physiology; D016032:Randomized Controlled Trials as Topic; D014717:Vertigo / Q000628:therapy*; D014732:Vibration / Q000627:therapeutic use