A Review of the Efficacy of Therapeutic Maneuvers in Posterior Canal Benign Paroxysmal Positional Vertigo

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:

Figure 1.

Flow chart of literature review (www.prisma-statement.org).

1. What is the success rate of Semont and Epley maneuvers in patients with PC BPPV?

2. What is the success rate of canalith repositioning or liberatory maneuvers as compared to no treatment or sham maneuver?

3. Is there any difference in success rate between traumatic and idiopathic cases?

4. Do postural restrictions following canalith repositioning maneuvers have an additional impact on success rate?

5. Does any medication with or without repositioning maneuvers have an impact on recurrence or residual dizziness?

6. 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).

Table 1.

Articles analyzing the success rate of Epley or Semont maneuvers as compared to no treatment or sham maneuver.

Study	BPPV	Treatment	Control	Method	Outcome
Herdman et al. 199316	PC	Epley (30) v Semont (30)	2 weeks and 6 months	Self-rated evaluation	Success 1 w and 6 mo Semont %70 - %90 Epley %57 - %90
Yakinthou et al. 200315	PC	Epley (40) v Semont (39)	1 week	DHT	Success; Epley 52.5%, Semont 51.35
Radtke et al. 200411	PC	Epley (37) v Semont (33)	1 week	DHT	Success; Epley 95%, Semont 58%
Steenerson et al. 200514	PC and LC	Epley (607) v Semont (233)	6 months	DHT	Success; Semont 98%, Epley 94%. Recurrence; Epley 12% Semont 21.8 %
Dispenza et al. 201210	PC	Epley (27) v Semont (30), HM (31)	2 and 4 weeks	DHT and VAS	Failure; Epley 22.2%, Semont 10%
Anagnostou et al. 201412	PC	Epley (51) v Semont (51)	2-5 hours	DHT	Success; Epley 76%, Semont 67%
Lee et al. 201413	PC	Epley (36) v Semont (32) and sham (31)	1 week	DHT	Success; Epley 63.9%, Semont 35.5%, sham 38.7%

Abbreviations: BPPV, Benign paroxysmal positional vertigo; PC, posterior canal; LC, lateral canal; CRM, canalith re-positioning maneuver; DHT, Dix-Hallpike test

Table 2.

Articles analyzing the success rate of Epley or Semont maneuvers as compared to no treatment or sham maneuver.

Study	BPPV	Treatment	Control	Outcome
Lynn et al, 19955	PC	CRM (18) v Sham (15)	1 month	Negative DHT 88.9% v 26.7%
Li, 199522	PC	CRM (60) v control (23) (untreated)	1 week	Negative DHT 60% without vibration 96% with vibration v 4%
Wolf et al, 19992	PC	CRM (31) v control (10) (untreated)	1 week	Success in one session 74% Failure 6.5% v 50%
Yimtae et al, 200323	PC	CRM (29) v control (29) (untreated)	4 weeks	Success at 4 weeks 75.9% v 48.2%
Angeli et al, 20033	PC	CRM (28) v control (19) (untreated)	1 month	Negative DHT 64.2% v 5.2%
Richard et al, 200518	PC	CRM (61) v control (20) (untreated)	1-6 months	Negative DHT 1 month; 89% v 10% 6 months; 92% v 50%
Von Brevern et al, 20066	PC	CRM (35) v Sham (31)	24 hours	Negative DHT 80% v 10%
Sekine et al, 200617	PC 127 LC 63	CRM (67) v control (60) Lempert (29) v control (34)	1 week and 1 month	Failure in DHT 1 week (PC) 20% v 51.7% 1 month (PC) 9.7% v 22.7% 1 week (LC) 7.1% v 30.9% 1 month (LC) 5.4% v 22.4%
Munoz et al, 200724	PC	CRM (38) v Sham (41)	7-14 days	Negative DHT 34.2% v 14.6%
Seo et al, 200719	PC	CRM (18) v control (16) (untreated)	24 hours 1 week	Negative DHT 24 hours; 67% v 6% 1 week; 72% v 25%
Chen et al, 201220	PC	Semont (65) v sham (63)	4th day	Negative DHT 84.6% v 14.2%
Mandala et al, 201221	PC	Semont (174) v sham (168)	24 hours	Negative DHT 86.8% v none
Bruintjies et al. 20141	PC	Epley (22) v sham (22)	1 year	Negative DHT 91% v 46%
Ballve et al, 201925	PC	Epley (66) v sham (68)	1 week, 1 month and 1 year	Negative DHT and self-rated evaluation at 1 week. 93.3% v 78.5%

Abbreviations: BPPV, Benign paroxysmal positional vertigo; PC, posterior canal; LC, lateral canal; CRM, canalith re-positioning maneuver; DHT, Dix-Hallpike test

Table 3.

Articles about the comparison of success rates in treatment of traumatic and idiopathic cases.

Study	Type of BPPV	Patients	Measure	Outcome
Gordon et al, 200427	PC	tBPPv (21) v iBPPV (42)	Symptom resolution 1st week and recurrence at 1 year	Success; t 23%, i 86% Recurrence; t 57%, i 19%
Ahn et al, 201131	PC-LC	tBPPV (32) v iBPPV (112)	Control at 5 days, 3 and 6 months	Success after first treatment; i 89.4%, t 59.6% Recurrence; t 15.6%, i 18.8% Multicanal; t 6.25%, i 3.37%
Suarez et al, 201129	All types	tBPPv (51) v iBPPV (325)	Control at 1 week and 4 months	Recurrence; t 23.5% i 32.9%
Liu et al, 201226	PC-LC	tBPPV (40) v iBPPV (46)	Symptom resolution 1st week and recurrence at 1 year	Success; t 35%, i 84%, Multicanal t 55%- i 6.5%, Recurrence;t 67%, i 12%
Pisani et al, 201530	PC-LC	tBPPv (716) v iBPPV (2344)	Recurrence at 1 year and rate of multiple maneuvers	Recurrence; i 18%, t 61% Cure after one maneuver; i 67.8%, t 47%, Rate of multiple maneuver; i 23% t 45%
Balatsouras et al, 201728	All types	tBPPv (33) v iBPPV (320)	Recurrence at 1 year and rate of multiple maneuvers	Success after first treatment; i 75.6%, t 33.3% Failure; i 7.5%, t 20%
Luryi et al, 201932	All types	tBPPV (110) v iBPPV (1268)	Control at 2 weeks, rate of resolution, recurrence, maneuvers	Resolution; t 70%, i 76.8% Recurrence; t 33.8%, i 38.7% Multiple maneuver; t 56.4%, i 43.6%

Abbreviations: BPPV, Benign paroxysmal positional vertigo; PC, posterior canal; LC, lateral canal; t traumatic; i, idiopathic

Table 4.

Articles about the comparison of outcome of canalith repositioning maneuvers with or without postural restrictions.

Study	Patients	BPPV and maneuver	Restrictions	Outcome Measure	Finding (WoR – WR)	Result
Marciano et al, 200233	100-100	PC-Epley	Sleep on high pillows 4 days	Symptom resolution	8.45%-10.9%	Insignificant
Gordon et al, 200427	50-25	PC-Epley	Neck collar 2 days	Symptom resolution at 2 weeks	84%-80%	Insignificant
Moon et al, 200534	35-35	PC-Epley	Sleep on high pillows 5 days	Symptom resolution in a week	9.1%-12.5%	Insignificant
Roberts et al, 200540	21-21	PC-Epley	Cervical collar, sleep on high pillows 4 days, avoid lying on affected ear	Symptom resolution in a week	9.5%-4.76%	Insignificant
Simoceli et al, 200539	23-27	PC-Epley	Sleep on high pillows 3 days	Symptom resolution at 3 days 50-25	21.7%-37%	Insignificant
Cakir et al, 200638	62-57	PC-Epley	Cervical collar for 2 days	Symptoms at 5 days and number of maneuvers for cure	2.6%-10.7%	Significant
Casqueiro et al., 200843	207-184	PC-Epley	Cervical collar 2 days, avoid lying on affected ear 10 days	Symptom resolution in 10 days and recurrence	3.1%-2.3%	Insignificant
Fyrmpas et al, 200935	32-32	PC-Epley	Sleep on high pillows 2 days, avoid lying on affected ear	Success with symptom resolution, 10-point scale at 2 days	74.2%-90%	Insignificant
De Stefano et al, 201136	7-37	PC-Epley and Semont	Cervical collar 2 days, avoid lying on affected ear 10 days	Symptom resolution at one week and DHI	8.1%-16.2%	Insignificant
Papacharalampous et al, 201241	41-41	All canals Epley, Vanucchi,	Cervical collar 2 days, to avoid lying on affected canal5 days	Symptom resolution in one week and recurrence at 12 months	82.9%-85.3% 17.01%-14.6%	Insignificant
Balikci et al, 201442	39-39	PC-Epley	Sleep on high pillow 10 days, avoid lying on affected ear	Early (10 days) and late (90 days) recurrence	5.4%-8.1%	Insignificant
Stewart et al, 201737	263-361	PC-Epley	Cervical collar 2 days	Success with symptom resolution	82.8%-84%	Insignificant

Abbreviations: BPPV, Benign paroxysmal positional vertigo; PC, posterior canal; DHI, dizziness handicap inventory; WR, with restriction; WoR, without restriction

Table 5.

Articles about the comparison of re-positioning maneuvers (Epley or Semont) and the medication only.

Study	Type of BPPV	Treatment	Follow-up protocol	Control	Outcome
Itaya et al, 199745	PC	Epley (15) v Semont (14) and drug alone (26); (vit B12, Diazepam Betahistine, Antivert)	DHT	Control at 3, 7 and 14 days	Epley %93.3, Semont 78.6%, Medication only 30.8%
Salvinelli et al, 200446	PC	Semont (52) v Flunarizine (52) and no treatment (52)	Negative DHT and Vertigo questionnaire	1 week intervals upto 6 months	Success; Semont 85%, Flunarizine 57.7%, no treatment 34.6%
Sundararajan et al, 201147	PC	Epley (25) v Epley + Cinnerazine (26)	DHT and self-rated evaluation	Control at 1 and 4 weeks	Complete cure at 4 weeks; Epley 84% Epley + drug 57%
Guneri et al, 201248	PC	Epley (22) v Epley + placebo (26) and Epley + Betahistine (24)	DHI, VDADLS, EEV, VSS and DHT	Control at 2 weeks	Success; No difference 86.9%, 84.7%, 97.5%
Jung et al, 201251	All types	Medication (etizolam) (39) v no treatment (34)	RD after successful maneuver; SVV, DHI and ABC	2 weeks	No significant difference between groups in DHI, ABC scores and SVV tilting
Maslovara et al, 201255	PC	Epley (45) v Betahistine (46)	Symptom resolution DHT and DHI	1 and 8 weeks	Resolution at 1st week Epley 93.3%, Medication 86.9%
Otsuka et al, 201349	PC-LC	Epley (194), Lempert (31) Betahistine (38)	DHT, Roll-on test	Follow-up 1-6 years	Resolution time is significantly shorter for maneuver groups.
Kim et al, 201453	PC-LC	Dimenhydrinate (45) v placebo (46) and no treatment (47)	Improvement in RD after successful Epley; DHI	1 week	Success; vestibular suppressant 67%, Placebo 47% and no treatment 43%
Sacco et al. 201444	PC	Epley (15) v Medication, (Diazem, antiemetic, antihistaminic) (11)	Symptom resolution DHI and phone follow-up	2 hours at ER and phone-call at 30 days	No significant difference
Kaur et al, 201750	PC	Epley (30) v Epley + Betahistine (30) and Betahistine alone (30)	Symptom resolution and recurrence DHI, VAS and DHT	4 weeks follow-up	Significant Epley + Betahistine 94.8%, Betahistine 87.1%
Casani et al, 201954	PC	Epley (131) v Epley + Polyphenol compound suppl (127)	Improvement in RD after successful Epley; DHI, VAS, SP and DHT	Control at 1st and 2nd month	Efficacy at 1st and 2nd month Polyphenol 81% and 91% No drug 90%
Jalali et al, 202052	PC	Betahistine (39) Dimenhydrinate (39) Placebo (39)	Improvement in RD after successful Epley; DHI and BBS	1 week	Betahistine; 58.6% Dimenhydrinate; 44.8% Placebo; 26.7%

Abbreviations: BPPV, Benign paroxysmal positional vertigo; PC, posterior canal; LC, lateral canal; DHT, Dix-Hallpike test; VSS, visual symptom scale; DHI, dizziness handicap inventory; SVV, subjective visual vertical RD residual dizziness SP Static posturography; ER; Emergency room; BBS, Berg balance scale; EEV, European evaluation of vertigo; ABC, Activities-specific balance confidence; VDADLS, Vestibular disorders activities daily living scale

Table 6.

Articles about the comparison of re-positioning maneuvers (Epley or Semont) and vestibular exercises.

Study	Type of BPPV	Treatment	Method	Control	Outcome
Steenerson et al,199656	PC	Epley (20) v VH (20) and control (no treatment – 20)	DHT	Weekly control for 1 month, 3 months	Success; Epley 82%, VH 63%, control 25%
Radtke et al, 199957	PC	Epley (28) v BDE (26)	DHT	1 week	Success; Epley 64% BDE 23%
Soto Varela et al, 200158	PC	Epley (20) v Semont (35) v BDE (52)	DHT	1 week, 1 month, 3 months	Success; Semont 74%, Epley 71%, BDE 24%
Cohen et al 20059	PC	Epley (24) v Semont (25), BDE (25) and sham (25)	DHT, self-rated evaluation, CDP	1st week, 3rd month and 6th month	Epley and Semont significantly better than BDE and sham P=0.033
Chang et al, 200862	PC	Epley (13) v Epley + VE (13)	SBT, TWT, DGI, self-rated measure	At 2 and 4 weeks	Epley + VE has better SBT and DGI scores (P<0.005)
Karanjai et al, 201059	PC	Epley (16) v Semont (16) and BDE (16)	DHT	2 weeks	Success; Epley 87.5%, Semont 75%, BDE 56.2%
Amor-Dorado et al, 20128	PC	Epley (41) v BDE (40)	DHT	1 week and 1 month	Success; Epley 80.5%-92.5%, BDE 25%-42.5%
Gupta et al, 201961	PC	Epley (30) v Semont (30) and BDE (30)	DHT and VAP QoL analysis	2 weeks	Success; Epley 90%, Semont 73%, BDE 50%
Rodrigues et al, 201960	PC and LC	Epley (15) v Epley + CCVE (17)	DHI, VAS, DH and roll-on Tests	1st, 3rd and 6th months	Epley + CCVE has significantly higher VAS scores (P=0.0023)

Abbreviations: BPPV, Benign paroxysmal positional vertigo; PC, posterior canal; LC, lateral canal; DHT, Dix-Hallpike test; VAS, Visual analogue scale; BDE, Brandt-Darroff exercises; QoL, Quality of life; VE, Vestibular exercises; VH, Vestibular habituation; CDP; Computerized dynamic posturography, SBT; Static balance test, TWT; Tandem walk test, DGI; Dynamic gait index, CCVE, Cawthorne-Cooksey exercises; VAP, Vestibular activities and participation scale

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.