Abstract
Benign paroxysmal positional vertigo (BPPV) is associated with significant functional impairment with the change of head position with respect to gravity. Therapeutic maneuvers provide relief of symptoms; however, some patients may have persistent symptoms and can be significantly disabled. The aim of this study is to review the critical factors that may have an impact on outcome. Six main categories that may possibly affect the outcome of therapeutic maneuvers in patients with posterior canal (PC) BPPV were selected. A review of the 1095 articles on therapeutic maneuvers in patients with PC BPPV was conducted by means of a search in PubMed, Embase, and Scopus databases between 1989 and 2020. We documented 14 articles about the comparative analysis of success rate of Semont and Epley maneuvers, 7 articles about the comparative analysis of success rate of therapeutic maneuvers and no treatment or sham maneuver, 7 articles about the comparison of success rate in treatment of traumatic and idiopathic cases, 12 articles about the comparison of outcome of repositioning maneuvers with or without postural restrictions, 12 articles about the comparison of success rate of medication and therapeutic maneuvers, and 9 articles about the comparison of vestibular exercises and therapeutic maneuvers. In conclusion, therapeutic maneuvers provide better outcome as compared to no treatment or sham maneuver. Epley maneuver has greater success rate than Semont maneuver. Traumatic cases are prone to develop more recurrences than idiopathic cases and have lower rate of symptom resolution. Body restrictions following successful repositioning maneuver has no impact on recurrence. Medical therapy or vestibular exercise alone is not an alternative to therapeutic maneuvers. However, the rate of residual dizziness is low when the vestibular exercises are combined.
Benign paroxysmal positional vertigo (BPPV) is one of the most common peripheral vestibular pathologies. Main symptoms include episodic and transient spinning sensation associated with rapid head movement that frequently occurs with turning in bed or changing position.1,2 A specific cause is often not found; in such cases, idiopathic BPPV is diagnosed. However, head injury, migraine, Meniere’s disease, osteoporosis, vitamin D insufficiency, infection, and vestibular neuronitis are reported to be associated with BPPV. Although BPPV can occur at any age, it is most often seen in elderly people.3 The underlying mechanism involves freely floating otoliths inside the semicircular canal, which is claimed to be due to utricular degeneration.4 An inner ear pathology that detaches the utricular otoconia appears to be capable of causing BPPV. The most common type of BPPV is the posterior canal (PC) BPPV, because it has lowest anatomical position of the vestibule in both upright and supine positions, which facilitates gravity-dependent accumulation of otoconia. The diagnosis is typically made when head-hanging maneuver results in positional nystagmus, which has a latency and can be fatigued. Canalith re-positioning (Epley), which is slowly rotating the head 90 degrees to the healthy side while the patient is in head-hanging position, and the liberatory (Semont) maneuver, in which the patient is seated on a treatment table and quickly lies on the affected side with the head rotated 45 degrees toward the unaffected side and then lies on the opposite side with the head in the same position have been found to be effective.5,6 The aim is to allow the displaced otoconia from the affected semicircular canal to be relocated back into the utricle. However, recurrence rate of the first year rises in the long period.7 Medical treatment or exercises may be helpful for residual dizziness. The aim of this study is to review the comparative studies related with the treatment of PC BPPV and clarify the critical factors that may have an impact on successful outcome.
Material and Methods
A review of the literature on therapeutic repositioning or liberatory maneuvers in patients with BPPV was conducted, with data extracted only from articles written in English. The articles were identified by means of a search in the PubMed, Embase, and Scopus databases using the keywords benign paroxysmal positional vertigo, Epley, Semont, liberatory, canalith/particle re-positioning, sham, medication, vestibular exercises, Brand-Darrof, Cawthorne-Cooksey, recurrence, residual dizziness, idiopathic, traumatic, postural restriction. A total of 1095 articles were reviewed for the study, and 60 articles were included for quantitative analysis, after we had excluded those that were technical or case reports, those based on experimental or animal studies, those that focused on the clinic, diagnosis, pathophysiology, etiology, prevalence, incidence, or mechanism other than the outcome, and those reports based on surgical treatment. Studies about children or adolescents with paroxysmal positional vertigo and studies with down-beating positional nystagmus or anterior or lateral canal BPPV only were excluded. Articles about treatment of PC BPPV were particularly selected. Articles about different types of treatment methods other than Semont or Epley were excluded. Those that were associated with secondary inner ear problems like vestibular neuronitis, Meniere’s disease, or migraine other than idiopathic or traumatic forms were excluded. Meta-analytic studies on a subject were particularly included if the outcome measures were clear. The search only included articles published between 1989 and 2020. If there was more than one article by the same author(s) or institution, only the most recent one matching the criteria and those that were not overlapping were included. Flow chart of the review has been presented as Figure 1 (Prisma 2009; www.prisma-statement.org). Six factors associated with the success of treatment were identified and listed:
Flow chart of literature review (www.prisma-statement.org).
What is the success rate of Semont and Epley maneuvers in patients with PC BPPV?
What is the success rate of canalith repositioning or liberatory maneuvers as compared to no treatment or sham maneuver?
Is there any difference in success rate between traumatic and idiopathic cases?
Do postural restrictions following canalith repositioning maneuvers have an additional impact on success rate?
Does any medication with or without repositioning maneuvers have an impact on recurrence or residual dizziness?
What is the success rate of vestibular exercises as compared to repositioning maneuvers?
Articles grouped according to the above mentioned criteria were separately reviewed and documented in detail in tables.
Results
After searching articles regarding BPPV, the following results were documented. Fourteen articles were about comparative analysis between canalith re-positioning and no treatment or sham maneuver. The data of the fourteen studies analyzing the success rate of Epley or Semont maneuvers as compared to no treatment or sham maneuver are summarized in Table 1. Seven articles were about the comparison of success rate of Semont and Epley maneuvers in patients with posterior canal BPPV (Table 2). Seven articles were about comparison of success rate in treatment of traumatic and idiopathic cases (Table 3). Twelve articles were associated with comparison of outcome of canalith repositioning maneuvers with or without postural restrictions (Table 4). Twelve articles were about comparing the success of medication (steroids, Betahistine, antiemetics, antihistaminics, vestibular suppressants, anti-cholinergics, etc.) and re-positioning maneuvers in patients with BPPV (Table 5). Nine articles were about comparison of vestibular exercises and therapeutic maneuvers in patients with BPPV (Table 6).
Articles analyzing the success rate of Epley or Semont maneuvers as compared to no treatment or sham maneuver.
Articles analyzing the success rate of Epley or Semont maneuvers as compared to no treatment or sham maneuver.
Articles about the comparison of success rates in treatment of traumatic and idiopathic cases.
Articles about the comparison of outcome of canalith repositioning maneuvers with or without postural restrictions.
Articles about the comparison of re-positioning maneuvers (Epley or Semont) and the medication only.
Articles about the comparison of re-positioning maneuvers (Epley or Semont) and vestibular exercises.
Discussion
Semont vs Epley Maneuver in Patients with Posterior Canal BPPV
In 1980, a few years before the introduction of therapeutic maneuvers, Thomas Brandt and Robert Barry Daroff proposed a form of home-based “habituation exercises” to treat patients with BPPV. The side of BPPV was not important, and the mechanism was based on the assumption that cupulolithiasis was the only underlying pathology at that time. They tried to manage the vestibular dysfunction by stimulating the vestibular system with eye, head, and body movements to promote adaptation and compensation process, eventually resulting in resolution of symptoms. Dr. Alain Semont was the first who intended to move the debris out of the posterior semicircular canal to a less sensitive location. He described a “liberatory maneuver” in 1988, which was quite similar to the Brandt-Darroff exercises. Canalith repositioning maneuver for PC BPPV was defined by John Epley in 1992.8,9 The mechanism of freely floating otoconial debris inside the semicircular canal provoking head movement related symptoms has been well understood, and Semont and Epley maneuvers have been the first line treatment for years. Interestingly, between 1993 and 2020, seven studies based on comparison of success of Semont and Epley maneuvers regarding symptom resolution and recurrence in patients with PC BPPV have been documented. Semont maneuver was clearly superior in only one study.10 Results were in favor of Epley maneuver in three studies.11-13 Two other studies presented similar success rates.14,15 However, recurrence was high in patients treated with Semont maneuver in one of those reports, which has the largest series.15 One study demonstrated a greater success rate with Semont maneuver at the early period; however, the results were the same at 6 months.16
Canalith Repositioning Maneuver vs No Treatment or Sham Maneuver
Canalith re-positioning and liberatory maneuvers has been proven to be effective in patients with BPPV. However, recurrence is an important functional and emotional issue in some patients. Furthermore, residual dizziness and impairment of postural control is not rare in patients who undergo re-positioning treatment with successful results. In the natural course of BPPV, some patients may have spontaneous remission. The mechanism behind the spontaneous remission is unclear. Some authors claim this might be due to patient’s self-made maneuver during sleep. The patient may get dizzy when he turns to the pathologic side during sleep. He then turns to the other side unconsciously and completes a therapeutic maneuver. It is important to review the comparative studies, whether a proposed maneuver provides better outcome than leaving the patient untreated.17 Studies indicate the rate of relief of symptoms following canalith re-positioning or liberatory maneuvers is prominent as compared to no treatment or sham maneuver ranging between 93.3% and 64.2%.1-3,17-21 None of the articles reports better success rates if the patients are left untreated. Randomized clinical trials indicate that recurrence is significantly higher if the patient is not treated, even if he feels well for a while.22-25
Traumatic vs Idiopathic BPPV
Trauma is an important and challenging etiological factor in development of BPPV, since traumatic cases are more resistant to treatment. Multiple therapeutic sessions are required, most probably due to greater amount of otoconial detachment and high occurrence of multichannel cases. However, studies comparing therapeutic outcome of idiopathic and traumatic cases are very few. Five of the seven studies report better success and lower recurrence rates in patients with idiopathic BPPV as compared to patients with traumatic BPPV.26-30 One study reports symptom resolution is better in patients with idiopathic BPPV, but the rate of recurrence is the same.31 In another study, symptom resolution and the rate of recurrence in traumatic and idiopathic cases is not different.32
Canalith Repositioning Maneuver With or Without Postural Restriction
One of the major concerns following a successful re-positioning or liberatory maneuver is the re-entry of otoconial debris and formation of new accumulation, which may be connected with recurrence. Body restrictions like using a cervical collar, sleeping on high pillows, lying on the affected ear, avoiding physical activities for a period of time have been subject of many studies to investigate whether these precautions have an impact on success rate. The impact of postural restrictions over symptom resolution is insignificant in majority of studies.33-39 One study reported that body restrictions provided higher rate of symptom resolution at earlier periods and lower number of maneuvers for ultimate cure.40 Studies analyzing the impact of postural restrictions on recurrence rate following successful therapeutic maneuvers presented no significant difference.41-43
Canalith Repositioning Maneuver With or Without Medication
Maneuvers and vestibular suppressants may have similar results in an emergency setting.44 However, the reports about symptom resolution in the follow-up are different. Itaya et al45 treated their patients with Semont or Epley maneuvers and compared the outcome of treatment by medication alone (betahistine, vitamin B12, diazepam, antivertiginous drugs, etc.). Control at 2 weeks revealed 93.3% and 78.6% success rates with Epley and Semont maneuvers, respectively. Medication provided symptom resolution in 30.8% of patients. Salvinelli et al46 have reported greater success rate with Semont maneuver (85%) as compared to flunarizine alone (57.7%) or no treatment (34.6%). Sundararajan et al47 reported that combination of Epley maneuver with a labyrinthine sedative (cinnerazine) has lower success rate as compared with Epley maneuver. Guneri et al48 compared the success rate of Epley maneuver alone with Epley maneuver plus placebo and Epley maneuver plus betahistine and found no significant difference.48 Studies comparing Epley maneuver and betahistine alone present better results in favor of the maneuver.49,50 Articles focusing on improvement in residual dizziness after successful maneuver present conflicting results. Some reports present no difference between the drugs and placebo or no treatment.51 However, higher beneficial effect of vestibular suppressants and betahistine as compared to placebo have been reported.52,53 Medication does not seem to be an alternative to re-positioning maneuvers. Vestibular suppressants should be avoided so as not to reduce the mobility of patients with BPPV. However, a combination of drugs with therapeutic maneuvers that are proven to improve vestibular microcirculation may be helpful to reduce the sense of residual discomfort.54,55
Canalith Repositioning Maneuver vs Vestibular Exercises
The role of vestibular exercises in the treatment of BPPV in combination with maneuvers or alone has been the subject of discussion after emergence of therapeutic maneuvers. Should individuals with BPPV restrict activities following maneuvers or do exercises provide better symptom resolution? Comparison of success rate following repositioning maneuvers and vestibular exercises in patients with BPPV has been investigated in a few randomized studies. Results indicate that vestibular exercise is not an alternative to repositioning or liberatory maneuver in terms of symptomatic relief and does not provide an extra benefit in prevention of recurrence.8,9,56-60 However, residual dizziness is much better and functional recovery is more effective when repositioning maneuver is combined with vestibular exercise.61,62 Studies are in favor of the positive contribution of rehabilitation therapy with exercises in terms of better quality of life scores.
Conclusion
Analysis of studies based on comparison of liberatory or re-positioning maneuvers with no treatment or sham maneuver indicates that therapeutic maneuvers provide significantly better outcome. Epley maneuver has greater success rate than Semont maneuver in patients with PC BPPV. Traumatic cases are prone to develop more recurrences than idiopathic cases and have lower rate of symptom resolution. Body restrictions following successful repositioning maneuver has no impact on recurrence. Medical therapy or vestibular exercise is not an alternative to re-positioning maneuver. However, the rate of residual dizziness is low when vestibular exercises are combined with repositioning maneuvers.
Footnotes
Disclosure: The authors have not declared any funding or conflicts of interests related to this article.
- Received April 21, 2021.
- Revision received March 7, 2022.
- Accepted April 6, 2022.
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