Epley Maneuver | Posterior BPPV Treatment | Vertigo Treatment
Benign paroxysmal positional vertigo, abbreviated as BPPV is the most common inner ear problem and cause of vertigo, or a false sense of spinning. Common causes are head trauma or ear infections, although most cases appear to be idiopathic.BPPV can be caused by debris in the semicircular canal of the ear, which continues to move after the head has stopped moving. This causes ongoing movement that conflicts with other sensory information.
The semicircular canals are filled with a fluid called endolymph. The main sense organ in each canal is called the crista, which is stimulated by the movement of the cupula. Head movement causes relative movement of the endolymph in the semicircular canal, which bends the cupula and the embedded hairs of the hair cells and causes stimulation of the relevant vestibular nerve. The cause of BPPV is believed to be canalithiasis, affecting the posterior semicircular canal in 85 to 95% of all cases. In canalithiasis, free-floating debris in the semicircular canal is hypothesized to act as a plunger, causing continuing movement of the endolymph even after head movement has ceased. This causes movement of the cupula and bending of the hairs of the hair cells and provokes vertigo.
Around 20% of BPPV cases are said to resolve within 4 weeks and up to 50% up to 3 months without treatment, but recurrence is reported between 10-18% after 1 year. The modified Epley maneuver involves a series of four movements of the head and body in order to move the debris out of the posterior semicircular canal.
In a Cochrane review by Hilton et al. (2014), the authors found that the Epley maneuver was more effective than sham maneuvers or control. There was no difference when Epley was compared to the Semont maneuver. The chance of success in this review was described to be as high as 80%. Be aware that the Epley maneuver can lead to nausea which was reported in 17-32% of patients. So make sure you have a bucket at hand, in case your patient might need it. The patient should be counseled that his symptoms of vertigo will be reproduced and that he might feel nauseous. On top of that, make sure that your patient is able to tolerate neck movement.
To perform the modified Epley maneuver have your patient sit on the treatment bench in long-sit with a pillow on the table that will make sure that the patient’s head is extended to 20° in a second. Rotate your patient’s head 45 degrees to the right in order to perform the maneuver for the right posterior semicircular canal. So if your Dix-Hallpike test was positive in this position, this is how you start. The steps are an exact mirror for the left side. Now take the patient backward in a quick movement so that your patient’s head is still rotated and extended to 20 degrees by the pillow. Maintain this position for 20-30s. Next, quickly turn your patient’s head 90 degrees toward the unaffected side and hold this position for another 20 seconds. Afterward, have your patient roll onto his left shoulder and quickly turn his head a further 90 degrees so that his head is facing down at a 45° angle. Again, hold this position for 20-30 seconds. Afterward, bring the patient into the upright sitting position to complete the maneuver. A meta-analysis from Devaiah et al. from the year 2010 showed that post maneuver restrictions are not necessary as they have not shown any significant benefit compared to no restrictions.
The literature demonstrated beneficial effects of multiple treatment sessions for patients with persistent nystagmus following the initial maneuver. Be aware, that canal conversion from the posterior into the lateral semicircular canal occurs in 6-7%of those treated with canalith repositioning procedures. Therefore, it is important to recognize the canal variant of BBPV as well.
Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, Holmberg JM, Mahoney K, Hollingsworth DB, Roberts R, Seidman MD. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngology–Head and Neck Surgery. 2017 Mar;156(3_suppl):S1-47.
- Kim Hansen30/03/22
Vestibular Rehabilitation VESTIBULAR REHABILITATION
Really good and professional layout with Firat's professional experience as well as nice software touches by Physiotutors with questions in some videos for example. Firat approaches you in different ways of teaching with small videos, summaries, lectures and so on. Also fun to see that some of his references are people that I have a cooperation with here in Sweden. Even if there’s a whole division of information regarding vestibular hypofunction it would still be fun to have separate chapter for vestibular neuritis, but that’s just a small note. On the whole I’m totally happy and satisfied with this course, really good job done by Firat and Physiotutors, I will be keeping an eye out for more advanced courses in the future regarding this topic, maybe Firat can do a Masterclass version?Steve van Rijen26/03/22
Vestibular Rehabilitation VESTIBULAR REHABILITATION
By far the best course i ever had.
It will take you a lot of time and effort to make it your own.
But i can tell, the reward is great.
you won’t be disappointedMarine Gandin27/01/22
Vestibular Rehabilitation REALLY COMPLETE COURSE AND EASY TO LEARN
It takes me 6 full days to finish that course but it was a really good course!
I enjoyed every part of the “vestibular rehabilitation” by Firat.
I’m excited to start doing some practice with patient!
I didn’t need any further explanation but I saw that Firat answers very fast to the question on the unit.
Thank you very much for this amazing course!
Even if it is in an other language than mine, it was really easy to understand.
- Christiena den Tek28/12/21
Vestibular Rehab COMPLETE COURSE ABOUT DIZZINESS AND THE WAY TO TREAT FOR PHYSIO'S
In the past I finished/followed a few courses about dizziness and treatment. I really enjoyed following this course because it’s very complete. There is overall information about the systems involved with dizziness problems, the pathologies, the exams and the overall physiotherapy treatment or other treatments. There is a nice mix between the way the information is given and the information is up to date science. The teacher (Firat) is a teacher that loves helping you out and if you have any questions he is quickly in his response.
I would recommened this course highly not only for those who just start learning things about the dizziness (patient) but also for those who are already working with these patients.Elisabetta12/12/21
Vestibular Rehabilitation INCREDIBLY THOROUGH COURSE
Such a fantastic course!
The learning experience is enhanced by interactive material found in each module.
The instructor provides clear information, both theoretical and practical, easy to apply in clinical practice.
This is an excellent course, and I would definitely recommend it!Physiotutors27/08/21
Vestibular Rehabilitation Firat really delivered on this course! While we have had some training in vestibular diagnostics and rehab in our own training, this course is on a whole other level! Building this course with Firat has increased our knowledge dramatically and we can absolutely recommend this course to any Physiotherapist as patients with vestibular problems will be among the most grateful patients when treated right.
- Anne Cahill02/08/21
Vestibular Rehabilitation Thank You!!
This is a brilliant course. The learning materials are concise, clear and comprehensive. All the information given is easy to navigate, up to date and very useful for daily clinical vestibular rehabilitation practice. It is a much appreciated educational resource. Amazing!! Thank you for this excellent course.Astrid Schubart27/06/21
Vestibular Rehabilitation I finished this course Vertigo this weekend and it’s been a long time since I’ve done such a great structured training. Lots of practical content. The lecturer shows in detail what is important. Firat Kesgin offers a lot of additional information and patient information.
I am really excited and looking forward to apply my new knowledge in practice.