Originally published online March 25, 2010 BPPV 2010.pdflithiasis,5 in which the otoconia freely sediment in the canals. Reori-entation of the canals causes the oto-conia to move to

doi: 10.2522/ptj.20090071Originally published online March 25, 2010

2010; 90:663-678.PHYS THER. and Timothy Carl HainJanet Odry Helminski, David Samuel Zee, Imke JanssenVertigo: A Systematic Reviewthe Treatment of Benign Paroxysmal Positional Effectiveness of Particle Repositioning Maneuvers in

http://ptjournal.apta.org/content/90/5/663found online at: The online version of this article, along with updated information and services, can be

Collections

Vestibular System Disorders Systematic Reviews/Meta-analyses

Balance Training Balance

in the following collection(s): This article, along with others on similar topics, appears

e-Letters

"Responses" in the online version of this article. "Submit a response" in the right-hand menu under

or click onhere To submit an e-Letter on this article, click http://ptjournal.apta.org/cgi/eletters/90/5/663be accessed for free at: 1 e-letter(s) have been posted to this article, which can

E-mail alerts to receive free e-mail alerts hereSign up

at VA Medical CenterRoom 1100 on March 28, 2013http://ptjournal.apta.org/Downloaded from

http://ptjournal.apta.org/cgi/collection/balancehttp://ptjournal.apta.org/cgi/collection/balance_traininghttp://ptjournal.apta.org/cgi/collection/systematic_reviewshttp://ptjournal.apta.org/cgi/collection/vestibular_system_disordershttp://ptjournal.apta.org/letters/submit/ptjournal;90/5/663http://ptjournal.apta.org/subscriptions/etoc.xhtmlhttp://ptjournal.apta.org/

Effectiveness of Particle RepositioningManeuvers in the Treatment ofBenign Paroxysmal Positional Vertigo:A Systematic ReviewJanet Odry Helminski, David Samuel Zee, Imke Janssen, Timothy Carl Hain

Background. Benign paroxysmal positional vertigo (BPPV) is the most commoncause of vertigo.

Purpose. The purpose of this systematic review was to determine whether pa-tients diagnosed with posterior canal (PC) BPPV, based on positional testing, andtreated with a particle repositioning maneuver will show the resolution of benignparoxysmal positional nystagmus (BPPN) on the Dix-Hallpike Test performed 24hours or more after treatment.

Data Sources. Data were obtained from an electronic search of the MEDLINE,EMBASE, and CINAHL databases from 1966 through September 2009.

Study Selection. The study topics were randomized controlled trials (RCTs),quasi-RCTs, the diagnosis of PC BPPV, treatment with the particle repositioningmaneuver, and outcome measured with a positional test 24 hours or more aftertreatment.

Data Extraction. Data extracted were study descriptors and the informationused to code for effect size.

Data Synthesis. In 2 double-blind RCTs, the odds in favor of the resolution ofBPPN were 22 times (95% confidence interval�3.41–141.73) and 37 times (95%confidence interval�8.75–159.22) higher in people receiving the canalith reposition-ing procedure (CRP) than in people receiving a sham treatment. This finding wassupported by the results reported in 8 nonmasked quasi-RCTs. Studies with limitedmethodological quality suggested that a liberatory maneuver (LM) was more effectivethan a control intervention; there was no significant difference in the effectiveness ofthe LM and the effectiveness of the CRP; the self-administered CRP was more effectivethan the self-administered LM; and the CRP administered together with the self-administered CRP was more effective than the CRP administered alone. The Brandt-Daroff exercises were the least effective self-administered treatments.

Limitations. The limitations included the methodological quality of the studies,the lack of quality-of-life measures, and confounding factors in reporting vertigo.

Conclusions. Randomized controlled trials provided strong evidence that theCRP resolves PC BPPN, and quasi-RCTs suggested that the CRP or the LM performedby a clinician or with proper instruction at home by the patient resolves PC BPPN.There were no data on the effects of the maneuvers on outcomes relevant to patients.

J.O. Helminski, PT, PhD, is Associ-ate Professor, Department ofPhysical Therapy, MidwesternUniversity, 555 31st St, DownersGrove, IL 60515 (USA). Address allcorrespondence to Dr Helminskiat: [email protected].

D.S. Zee, MD, is Professor, Depart-ments of Neurology, Ophthalmol-ogy, Otolaryngology, and Pathol-ogy, School of Medicine, TheJohns Hopkins University, Balti-more, Maryland.

I. Janssen, PhD, is Assistant Profes-sor, Department of PreventiveMedicine, Rush University MedicalCenter, Chicago, Illinois.

T.C. Hain, MD, is Professor, De-partments of Physical Therapy andHuman Movement Science, Oto-laryngology, and Neurology,Northwestern University MedicalSchool, Chicago, Illinois.

[Helminski JO, Zee DS, Janssen I,Hain TC. Effectiveness of particlerepositioning maneuvers in thetreatment of benign paroxysmalpositional vertigo: a systematicreview. Phys Ther. 2010;90:663–678.]

© 2010 American Physical TherapyAssociation

Research Report

Post a Rapid Response tothis article at:ptjournal.apta.org

May 2010 Volume 90 Number 5 Physical Therapy f 663 at VA Medical CenterRoom 1100 on March 28, 2013http://ptjournal.apta.org/Downloaded from

http://ptjournal.apta.org/

Benign paroxysmal positionalvertigo (BPPV) is characterizedby brief periods of vertigo trig-gered by a change in the position ofa person’s head relative to gravity. Inthe general population, the lifetimeprevalence of BPPV is 2.4%, and the1-year incidence is 0.6%.1 It is themost common vestibular disorder,accounting for one third of vestibu-lar diagnoses in the general popula-tion.1 Benign paroxysmal positionalvertigo can affect the quality of life ofelderly patients and is associatedwith reduced activities of daily liv-ing, falls, and depression.2 Patientswith BPPV experience delays in diag-nosis and treatment, the mean delaybeing 92 weeks, and they frequentlyare inappropriately treated with ves-tibular suppressant medications.3

Benign paroxysmal positional ver-tigo is caused by abnormal mechan-ical stimulation of 1 or more of the 3semicircular canals within the innerear (Fig. 1). The fluid-filled canalsnormally act to detect rotation of thehead through the deflection of sen-sory hair cells embedded within agelatinous membrane, the cupula.The weighted sensory membrane ofthe maculae normally acts to detectgravitational forces on the head. InBPPV, calcite particles (otoconia),which normally weight this mem-brane, become dislodged and sedi-ment in the canals, changing the dy-namics of the canals. There are 2primary theories for the mechanismof BPPV. The first is cupulolithiasis,4

in which the dislodged otoconia di-

rectly attach to the cupula, weight-ing this membrane. Reorientation ofthe canal relative to gravity deflectsthe cupula, exciting or inhibiting theampullary organ. The second is cana-lithiasis,5 in which the otoconiafreely sediment in the canals. Reori-entation of the canals causes the oto-conia to move to the lowest part ofthe canals, creating a drag on theendolymph, resulting in fluid pres-sure on the cupula, and activatingthe ampullary organ.

The Dix-Hallpike maneuver,6 re-ferred to as the Dix-Hallpike Test(DHT) in this article, is the standardfrom which the diagnosis of poste-rior canal (PC) BPPV is made anddifferentiated from other condi-tions.7,8 The diagnostic criteria forPC BPPV are vertigo associated withcharacteristic ocular nystagmus thatis torsional (toward the dependentear) and directed upward, consistentwith the excitation of the ampullaryorgan of the PC9; a 1- to 40-secondlatency before the onset of vertigoand nystagmus10–12; and vertigo andnystagmus with a duration of lessthan 60 seconds.13 With repeated po-sitioning, PC BPPV temporarily be-comes less intense and disappears.13

For the DHT, the estimated sensitiv-ity and specificity are 79% (95% con-fidence interval [CI]�65–94) and75% (CI�33–100), respectively.14

The interrater reliability for inter-preting the direction of eye move-ment ranges from a mean percentageof agreement of 43% (fair) to a meanpercentage of agreement of 81%(substantial), depending on the levelof expertise.15

Treatment of BPPVOnce the involved canal is identified,BPPV often is treated with particlerepositioning maneuvers. These ma-neuvers move otoconia out of theaffected canal and back into the ves-tibule, where it is thought that theparticles dissolve.16,17

Historically, the first maneuvers usedfor BPPV were the Brandt-Daroff ex-ercises,10 which were designed tohabituate symptoms. The patient re-peatedly moved from sitting at theedge of the bed to lying on the side(side lying) with the head rotated 45degrees toward the ceiling. The pa-tient alternated between left side ly-ing and right side lying.

The canalith repositioning proce-dure (CRP), developed by Epley18

(Fig. 2A), was designed to use gravityto treat canalithiasis of the PC. Theclinician moves the patient througha series of 4 positions. With eachposition, the otoconia settle to thelowest part of the canal, movearound the arc of the PC, and finallydeposit in the vestibule. This proce-dure requires a 180-degree turn ofthe head19–21 and a return to a sittingposition from lying on the unin-volved side.21 To enable the otoco-nia to settle, each position is main-tained for at least 30 seconds.20

Vibration applied to the mastoidprocess of the involved side doesnot affect the outcome of the pro-cedure and is no longer considerednecessary.22–24

The liberatory maneuver, developedby Semont et al25 (Fig. 2B), was de-signed to use inertia and gravity totreat cupulolithiasis of the PC. Toevacuate the particles, the patient israpidly swung from lying on the in-volved side to lying on the unin-volved side through a 180-degreecartwheel motion with a duration ofless than 1.3 seconds.19

Both the CRP and the liberatory ma-neuver have been modified to enablea patient to self-treat. With the self-administered CRP,26,27 the patientmoves through the same positions asin the CRP, except that the head isextended over the edge of a pillow.With the self-administered liberatorymaneuver,27 the patient performsthe maneuver independently, with

Available WithThis Article atptjournal.apta.org

• The Bottom Line

• Audio Abstracts Podcast

This article was published ahead ofprint on March 25, 2010, atptjournal.apta.org.

Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo

664 f Physical Therapy Volume 90 Number 5 May 2010 at VA Medical CenterRoom 1100 on March 28, 2013http://ptjournal.apta.org/Downloaded from

http://ptjournal.apta.org/cgi/content/full/90/5/DC1http://ptjournal.apta.org/cgi/content/full/90/5/DC1http://ptjournal.apta.org/

no other modifications. Both exer-cises are stopped when the patienthas been vertigo free for at least 24hours.26,27

The role of activity restrictions in theoutcome of particle repositioningmaneuvers remains uncertain. Post-maneuver activity restrictions didnot improve the efficacy of treat-ment with the CRP28,29 or the libera-tory maneuver,28 but patients withno activity restrictions required 1 or2 more treatment sessions to achievea successful outcome.30

The DHT is critical for determiningthe outcome of particle reposition-ing maneuvers.7,31 The absence ofthe characteristic nystagmus indi-cates the resolution of PC BPPV.32

The patient’s report of vertigo ismore variable than the observationof the characteristic nystagmus onpositional testing. Patients showing

Figure 1.Mechanisms of benign paroxysmal positional vertigo. Reprinted with permission from American Dizziness and Balance. Copyright2007.

The Bottom Line

What do we already know about this topic?

Randomized controlled trials (RCTs) suggest that the canalith reposition-ing procedure (CRP) is more effective than a sham treatment in theresolution of posterior canal benign paroxysmal positional nystagmus (PCBPPN).

What new information does this study offer?

Evidence for the use of other particle repositioning maneuvers is weakdue to the limited numbers of studies and no RCTs. There is no significantdifference in the effectiveness of the CRP compared with the liberatorymaneuver (LM). If properly instructed, self-administered CRP and LM areeffective. The Brandt-Daroff habituation exercises are the least effective.The most effective treatment is a combination of the CRP and the self-administered CRP.

If you’re a patient, what might these findings mean foryou?

The CRP and LM performed by a clinician or, with proper instruction, bythe patient at home resolves PC BPPN.




Figure 2.Particle repositioning maneuvers. (A) Canalith repositioning procedure illustrated for treatment of the right posterior canal. The clinicianmoves the patient through a series of 4 positions, starting with the placement of the involved canal in the head-hanging position of theDix-Hallpike Test. To begin, the patient is positioned in the long sitting position (sitting on the treatment table with the legs extended).The patient’s head is rotated 45 degrees toward the right. The patient is then lowered into the supine position with the neck extended 20degrees over the edge of the treatment table; this is the head-hanging position. The head is rotated through 90 degrees of motion, endingin 45 degrees of neck rotation toward the uninvolved side. This step is followed by rolling onto the uninvolved side while maintaining thehead-on-trunk position and, finally, sitting up from lying on the uninvolved side. Each position is maintained for a minimum of 30 secondsor as long as the nystagmus lasts. The procedure is repeated 3 times. (B) Liberatory (Semont) maneuver illustrated for treatment of the rightposterior canal. The patient sits on the edge of the treatment table. The clinician rapidly moves the patient to lying on the involved sidewith the head rotated 45 degrees toward the uninvolved side. While maintaining the head-on-trunk position, the clinician swings thepatient from lying on the involved side to lying on the uninvolved side. The head then is gently tapped on the treatment table. Each positionis maintained for 1.5 minutes. The procedure is repeated 3 times. Reprinted with permission from American Dizziness and Balance.Copyright 2007.




the resolution of positional nystag-mus on the DHT may report vertigoif concurrent vestibular deficits ex-ist.33 Patients with positive findingson the DHT may report no vertigo atthe time of follow-up if provokingpositions are avoided or if they haveunrecognized BPPV (imbalance withno vertigo).2 Because of these con-founding factors, the patient’s reportof vertigo should not be the onlyoutcome measure.

The time interval between treatmentand outcome assessment is critical.To separate the effects of activetreatment from a fatigue response,outcome should be assessed 24hours or more after treatment.32 Re-peated positioning may cause a fa-tigue response that can mimic suc-cessful treatment.32 Within 7 days ofPC BPPV symptom onset, 30% of pa-tients will experience spontaneousremission.34 To minimize the possi-bility of spontaneous remission caus-ing a false-negative particle reposi-tioning maneuver outcome and toavoid a fatigue response, outcomeideally should be assessed 24 hoursafter treatment.

Patients with BPPV experience a de-crease in health-related quality of life,which is restored after successful re-mission of BPPV following treatmentwith a particle repositioning maneu-ver.35 However, health-related quality-of-life measures are not routinely usedin treatment outcome studies.

A published overview of the CochraneCollaboration (search dates: 1966–2004)36 and 2 meta-analyses37,38 evalu-ated the effectiveness of the CRP inthe treatment of BPPV but did not eval-uate other maneuvers. Two recentlypublished practice guidelines7,8 evalu-ated the effectiveness of the CRP, theliberatory maneuver, and the self-administered variants. These publica-tions included assessments of themethodological quality of the studiesevaluated. A rigorous qualitative syn-

thesis needs to include an evaluationnot only of the methodological qualitybut also of the precise performance ofthe intervention and the validity, reli-ability, and responsiveness of the testsused in the studies.39

The purpose of this systematic re-view was to determine whether pa-tients diagnosed with PC BPPV onpositional testing and treated with aparticle repositioning maneuver willshow the resolution of benign parox-ysmal positional nystagmus (BPPN)on the DHT performed 24 hours ormore after treatment. A synthesisof methodological quality was per-formed. The standards of method-ological quality for this systematicreview were randomization,40 alloca-tion concealment,41,42 masking,43

and sample size calculation.44 TheCRP, the liberatory maneuver, andthe self-administered variants wereevaluated. The inclusion and exclu-sion criteria were based on the find-ings of the proposed mathematicalmodels of the treatment of BPPV19–21

with the particle repositioning ma-neuvers to take into account thequality of the performance of the in-tervention and were based on theperformance of the DHT as an out-come measure to take into accountthe validity and reliability of theoutcome. The responsiveness of theDHT has not been reported in theliterature.

MethodData Sources and SearchesAn electronic literature search of theMEDLINE, EMBASE, and CINAHL da-tabases for the period from 1966through September 2009 was con-ducted with the medical subjectheading term “vertigo.” In MEDLINE,to refine the search, the medical sub-ject heading was combined with an“or” statement including “benignparoxysmal positional vertigo, BPPV,BPV, benign paroxysmal positionalnystagmus, BPPN, or BPN.” Thesearch was restricted to English (pos-

sibly introducing publication bias).In CINAHL, the search was repli-cated with the same terms. In EM-BASE, because of more specific index-ing, the search was performed withthe medical subject heading “ver-tigo” and the subheadings “BPPV”and “therapy.” A published over-view of the Cochrane Collaboration(search dates: 1966–2004),36 2 meta-analyses37,38 of the treatment of PCBPPV, and 2 practice guidelines7,8

were also reviewed. Bibliographiesof the identified articles were manu-ally searched for any additional rele-vant articles. The results of thesearches were compared, and dupli-cates were removed (Fig. 3).

Study SelectionPublished studies that reported onthe effectiveness of particle reposi-tioning maneuvers in the treatmentof PC BPPV were eligible for inclu-sion. The inclusion criteria (Tab. 1)were as follows:

1. The study design was a random-ized controlled trial (RCT) orquasi-RCT.

2. Participants had a clinical diagno-sis of unilateral typical BPPV (PCinvolvement) on the basis of thefindings on the DHT.7,8

3. A manual particle repositioningmaneuver was performed. If theCRP was used, it included all 4positions described originally byEpley18 to optimize the removalof loose otoconia from thePC.19–21 For the best outcome,simulated models of the CRP sug-gested from the initial head-hanging position a full 180-degreeturn of the head toward the unin-volved side and a return to theupright position from the unin-volved side.19–21 Acceptable mod-ifications to the original CRP in-cluded self-administration,26,27,45

performance of the procedure




Table 1.Inclusion and Exclusion Criteriaa

ParameterAngeliet al54

Asawavichiangindaet al55 Blakley56

Califanoet al57

Cavaliereet al58

Changet al59

Cohenand

Kimball60Froehling

et al49 Li61Lynn

et al33

Inclusion criteria

RCT, quasi-RCT � � � � � � � � �

Typical BPPV � � � � � � � � �

Intervention

Manual particlerepositioning maneuver

� � � � � � � � � �

CRP with positionsdescribed by Epley18

� � � � � � �

Administered by:

Clinician � � � � � � �

Self

Activity restrictionsafter treatment

Yes � � � � �

No � � � � �

Outcome

DHT or side-lying testto assess nystagmus

� � � � � � �

Outcome assessed�24 h and �1 mo aftertreatment

� � � � � �

Proportion of participantswho converted frompositive to negativeDHT results reported

� � � �

Exclusion criteria

Cohort, retrospective,case-control, or casestudy

�

No inclusion criteria �

Atypical BPPV

Bilateral PC BPPV �

Central nervoussystem dysfunction

Intervention: CRP withmodification of positionsdescribed by Epley18

� �

Outcome: no DHT orside-lying test toassess nystagmus

� � �

a RCT�randomized controlled trial, BPPV�benign paroxysmal positional vertigo, CRP�canalith repositioning procedure, DHT�Dix-Hallpike Test,PC�posterior canal.




Table 1.Continued

Parameter

Massoudand

Ireland28Munozet al62

Radtkeet al26

Radtkeet al27

Salvinelliet al50

Salvinelliet al51

Serafiniet al63

Shermanand

Massoud52

SotoVarelaet al53

Sridharet al64

Inclusion criteria

RCT, quasi-RCT � � � � � � � � �

Typical BPPV � � � � � � � � � �

Intervention


� � � � � � � � � �


� � � � � �

Administered by:

Clinician � � � � � � � �

Self � �


Yes � �

No � � � � � � � �

Outcome


� � � � � � � � � �


� � � � � � � � �


� � � � � � � � � �

Exclusion criteria


� �

No inclusion criteria

Atypical BPPV





(Continued)




without the use of vibration,22–24

no activity restrictions after theprocedure,28–30 and no premedi-cation to avoid nausea.

4. The successful outcome of a par-ticle repositioning maneuver wasdefined as the conversion of apositive DHT result to a negativeDHT result or side-lying test re-sult33 24 hours or more after theinitial treatment procedure toavoid the fatiguing response32 butless than 1 month later to sepa-rate the effects of active treat-ment from natural history.34

5. The proportion of participantswho showed conversion fromnystagmus to no nystagmus onthe DHT at the time of follow-upwas reported.

The exclusion criteria (Tab. 1) wereas follows:

1. The study was a cohort study, aretrospective study, a case-control study, or a case study.

2. No inclusion criteria weredescribed.

3. Participants had a clinical diagno-sis of atypical BPPV (lateral canalor anterior canal involvement), bi-lateral PC BPPV due to confound-ing variables,46 or central vestibu-lar deficit.

4. The head positions of the CRPoriginally described by Epley18

were modified. The CRP was per-formed with less than 180 de-grees of head rotation from theinitial head-hanging position anda return to the upright positionfrom the involved side.19–21

5. The successful outcome of a par-ticle repositioning maneuver wasdefined only as the resolution ofvertigo.

Table 1.Continued

ParameterTanimoto

et al45

vonBrevernet al32

Wolfet al65

Yimtaeet al66

Inclusion criteria

RCT, quasi-RCT � � � �

Typical BPPV � � � �

Intervention


� � � �


� � �

Administered by:

Clinician � � � �

Self �


Yes �

No � � �

Outcome


� � � �


� � � �


� � � �

Exclusion criteria


No inclusion criteria

Atypical BPPV




�





6. A successful outcome was assessedless than 24 hours after treatment.

7. The proportion of participantswho showed successful conver-sion from nystagmus to no nystag-mus on the DHT at the time offollow-up was not documented.

Data Extraction and QualityAssessmentAbstracts were screened. If the studywas an RCT or a quasi-RCT and thestudy population was diagnosedwith PC BPPV, then the article wasobtained and reviewed by 2 review-ers (J.O.H. and D.S.Z.). When dis-crepancies occurred, the reasonswere identified, and a final decisionwas made on the basis of the unani-mous agreement of the authors

(J.O.H., D.S.Z., and T.C.H.). Thestudies were stratified according tothe particle repositioning maneuver.

The methodological quality stan-dards for this systematic review wererandomization,40 allocation conceal-ment,41,42 masking,43 and samplesize calculation.44 Lack of randomiza-tion, allocation concealment, ormasking could change the treatmenteffects, resulting in study selectionand confounding biases. Lack of cal-culation of the sample size could re-sult in a greater risk of a type IIerror.44

Data were extracted, and a data formwas completed to evaluate the meth-odological quality and quality of theinterventions, tests, and outcomes of

each study. The data collection formconsisted of items compiled from acombination of instruments.39,47,48

Information was obtained on the set-ting, study design, patient selectionprocess, masking, intervention, out-comes, and statistics to evaluate thecomponents of internal validity (se-lection bias, performance bias, de-tection bias, and attrition bias) andexternal validity (patients, interven-tion, setting, and outcomes) for po-tential bias. In addition, we compiledthe following variables: patient re-port and quantitative outcomes onpositional testing at short-termfollow-up (first follow-up session)and long-term follow-up (if multiplefollow-up sessions, last session),complications, and postprocedureinstructions. When studies used re-

Figure 3.Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement flow diagram of the literature search.




peated follow-up periods, the short-est time between 1 and 30 days tofollow-up was used to allow for thestrongest association between treat-ment and outcome. Studies that metthe inclusion criteria were stratifiedaccording to the study design andintervention.

Data Synthesis and AnalysisTo assess the outcome of each study,the effect size was calculated. Thesuccessful outcome of a particle re-positioning maneuver was defined asthe conversion of a positive posi-tional test to a negative positionaltest (no BPPN). The patient’s reportof vertigo was not qualitatively ana-lyzed. Two-by-two contingency ta-bles were used to organize the out-come data. The odds ratio (OR) andthe 95% CI were calculated to deter-mine the odds of a successful out-come or a negative positional test.The OR measures the association be-tween treatment and outcome. Forquasi-RCTs comparing active treat-ments, the OR was calculated withthe standard treatment (control) asthe CRP. The CRP was selected asthe standard of treatment becausethe 2 RCTs supported its effective-ness.32,33 Only trials in which ran-domized treatment assignments anda clearly defined control group wereused were considered for inclusionin a meta-analysis. Because only 2such trials existed, a meta-analysiswas not performed. We includedquasi-RCTs and nonmasked trials inthe systematic review. We acknowl-edge that these studies may be bi-ased and may overestimate treat-ment efficacy.

Statistical analysis of the data wasperformed with SAS/STAT (version9.1).* All tests of significance wereperformed at an � level of .05.

ResultsInitially, 868 records were identifiedthrough an electronic database search(Fig. 3). From these records, 24 full-text articles were assessed for eligibil-ity on the basis of their titles and ab-stracts. After complete articles wereread, only 10 articles met the inclusioncriteria,27,28,32,33,45,49–53 and 14 met theexclusion criteria.26,54–66 The mainreasons for exclusion were study de-sign, inclusion criteria (no inclusioncriteria discussed or bilateral PC BPPVincluded), modifications to the headposition used in the CRP, outcome notmeasured with a positional test, out-come assessed less than 24 hours ormore than 1 month after treatment,and inadequate statistics (Tab. 1).

Of the 10 articles included in thequalitative synthesis, 2 studies usedsealed envelopes with a computer-generated randomization code32 or ablock randomization scheme (num-bered, sealed envelopes containingtreatment group assignments, pre-pared before the start of the study)33

to randomly allocate their partici-pants to groups. Two studies quasi-randomly allocated their partici-pants to groups on the basis of thedate of their first visit.51,52 Six studiesstated that participants were ran-domly allocated to groups but didnot describe the method of ran-domization.27,28,45,49,50,53 Maskingof participants and outcome oc-curred in 3 studies.32,33,49 None ofthe studies reported calculation ofthe sample size.27,28,32,33,45,49 –53 At-trition was described but was notincluded in statistical calculationsin 8 studies (intention-to-treat anal-ysis)27,28,32,33,45,49,52,53 and was notaddressed in the remaining 2 arti-cles.50,51 A summary of the itemsincluded to assess the methodolog-ical quality of the studies is pro-vided in Table 2.

Two RCTs32,33 and 2 quasi-RCTs49,52

compared the effectiveness of the CRPwithout vibration and the effective-

ness of a sham treatment.32,33,49,52 Atshort-term follow-up, the success ratesfor patients treated with the CRP were67% to 95%,32,33,49,52 those obtainedwith the sham treatment were 10% to38%,32,33,49,52 and that obtained withthe control was 60%.52 The magnitudeof the effect of the CRP comparedwith that of the sham treatment wassignificant in all 4 studies.32,33,49,52 Be-cause of the small sample sizes andthe wide confidence intervals, ho-mogeneity could not be determined.The odds in favor of symptom reso-lution in the RCTs were 22 to 37times higher in people receivingthe CRP32,33 and were more variablein the quasi-RCTs (3–25 timeshigher).49,52

Two quasi-RCTs compared the lib-eratory maneuver and no treatment(control).50,51 At short-term follow-up, the success rates for patientstreated with the liberatory maneuverwere 80% to 85%, whereas sponta-neous resolution in the controlgroup was 35% to 38%. The odds infavor of symptom resolution were 7to 10 times higher in patients receiv-ing the liberatory maneuver than inthe control group (Tab. 3). Theremay have been overlap of partici-pants in these 2 studies becausethe data were collected over thesame time periods by the sameauthors.50,51

Two quasi-RCTs compared the CRPand the liberatory maneuver.28,53 Atshort-term follow-up, the successrates were 71% to 93% for the CRPand 74% to 92% for the liberatorymaneuver. To calculate the OR, theCRP was selected as the standard oftreatment. The odds in favor ofsymptom resolution were 0.80 and1.16 higher in participants using theCRP, and the 95% CIs included 1,suggesting no significant differencein effectiveness between the libera-tory maneuver and the CRP.

* SAS Institute Inc, 100 SAS Campus Dr, Cary,NC 27513-2414.




Table 2.Summary of Methodological Qualitya

ParameterFroehling

et al49Lynn

et al33

Massoudand

Ireland28Radtkeet al27

Salvinelliet al50

Salvinelliet al51

Shermanand

Massoud52

SotoVarelaet al53

Tanimotoet al45

vonBrevernet al32

Setting Urgentcare/IM

Oto OP Oto/Neuro Oto Oto BD Oto Oto Oto/Neuro

Study design Quasi-RCT RCT Quasi-RCT Quasi-RCT Quasi-RCT Quasi-RCT Quasi-RCT Quasi-RCT Quasi-RCT RCT

Participant selection

Inclusion andexclusioncriteria

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Method ofrandomization

No Yes No No No No No No No Yes

Method of quasi-randomization

Yes Yes Yes Yes Yes Yes Yes Yes

Method ofrandomizationconcealed

No Yes No No No No No No No Yes

Baselinecomparability


Masking

Masking ofparticipants

Yes Yes No No No No No No No Yes

Masking ofoutcome

Yes Yes No No No No No No No Yes

Intervention

Treatmentprotocoladequatelydescribed


Control orplaceboadequate


Testing ofparticipantadherence totreatmentprotocol

No Yes No Yes No No No No Yes No

Description ofwithdrawaland dropouts

NA Yes NA Yes No No Yes Yes Yes Yes

Participantfollow-updetailsreported

Yes Yes Yes Yes No No Yes Yes Yes Yes

Follow-up periodadequate


Outcomes

Outcomemeasuredescribed


Relevantoutcomes used


(Continued)




Three quasi-RCTs reported the resultsof self-administered maneuvers27,45,53

(Tab. 3). All of these studies compared2 or more maneuvers. At 1 week, thesuccess rates were 90% to 95% for theself-administered CRP or the CRP ad-ministered together with the self-administered CRP,27,45 58% for theself-administered liberatory maneu-ver,27 and 24% for the Brandt-Daroffexercises.53 The low success rate forthe Brandt-Daroff exercises in thosestudies was contrary to the high suc-cess rate (98%) originally describedin a 2-week, nonrandomized trialwith longer treatment durations.10

To calculate the OR, the CRP wasselected as the standard of treat-ment. If CRP was not performed,then the self-administered CRP wasselected. The odds in favor of symp-tom resolution were only 0.13 timeshigher in participants using theBrandt-Daroff exercises (OR�0.13,95% CI�0.04–0.38) and 0.08 timeshigher in participants using theself-administered liberatory maneu-

ver (OR�0.08, 95% CI�0.02–0.38)(Tab. 3). The odds in favor of symp-tom resolution were 3.54 timeshigher (95% CI�1.02–12.30) withthe CRP plus the self-administeredCRP than with the CRP alone(Tab. 3), suggesting better outcomeswith the performance of a combina-tion of the CRP plus the self-administered CRP.

Two RCTs32,33 comparing the effec-tiveness of the CRP without vibra-tion and the effectiveness of a shamtreatment were eligible for quantita-tive synthesis. Because of the limitednumber of studies, a meta-analysiswas not performed.

DiscussionThis systematic review evaluated theeffectiveness of several particle repo-sitioning maneuvers, namely, theCRP, the liberatory maneuver, andthe self-administered variants, in thetreatment of PC BPPV. The presentsystematic review is a qualitative syn-

thesis of methodological quality. Ourinclusion and exclusion criteria tookinto account the quality of the per-formance of the intervention and theappropriateness of the tests and mea-sures used.

Our inclusion and exclusion criteriawere based on the findings of theproposed mathematical models forthe treatment of BPPV19–21 with theparticle repositioning maneuvers.We excluded studies that includedparticipants with bilateral BPPV toavoid confounding variables.56,64,65

We did not rate the methodologicalquality of the articles but provided adescription of the quality becausenot all of the qualitative scales ad-dressed the quality of the physicaltherapy interventions and the valid-ity, reliability, and responsiveness ofthe outcomes used.39

Our results agree with those of ear-lier reviews7,8,36–38—that the CRP ismore effective than a control in the

Table 2.Continued

ParameterFroehling

et al49Lynn

et al33

Massoudand

Ireland28Radtkeet al27

Salvinelliet al50

Salvinelliet al51

Shermanand

Massoud52

SotoVarelaet al53

Tanimotoet al45

vonBrevernet al32

Use ofquantitativeoutcomemeasure


Statistics

Descriptivemeasuresidentified andreported forprimaryoutcome


Appropriatestatistics used

Yes Yes Yes Yes No Yes Yes Yes Yes Yes

Sample sizecalculationperformed

No No No No No No No No No No

Adequate samplesize


Intention-to-treatanalysis used

NA No NA No No No No No No No

a IM�internal medicine, Oto�otolaryngology, OP�outpatient, Neuro�neurology, BD�balance and dizziness, RCT�randomized controlled trial, NA�notavailable.




treatment of PC BPPV. On the basisof our inclusion and exclusioncriteria, only 2 studies32,33 met thecriteria for quantitative synthesis;therefore, a meta-analysis was notperformed. The greater variability inthe quasi-RCTs may have been due to

the clinical expertise of the studypersonnel49 or to a difference in thepatient populations. Professionalswere trained to evaluate ocular nys-tagmus during positional testing.49

The interrater reliability for inter-preting the direction of eye move-

ment varied depending on the levelof expertise.15 The low OR may re-flect the lack of experience of thetrained professionals in evaluatingeye movements and may support theneed for experienced professionalsto treat BPPV to minimize delays in

Table 3.Information Used to Code for Effect Size

Study Group

Outcome Outcome Measures

No. ofParticipants/

Group

No. ofParticipants

WithNegative

Dix-HallpikeTest Result

% ofParticipants

Cured

ReportedLevel of

Significance(P) Groups

Odds Ratio(95% Confidence

Interval)

Lynn et al33 CRP 18 16 89 �.001 CRP vs sham 22.0 (3.41–141.73)

Sham 15 4 27

Massoud andIreland28,a

CRP 46 43 93 �.2b LM vs CRP 0.80 (0.17–3.79)

LM 50 46 92

Froehling et al49 CRP 24 16 67 .046 CRP vs sham 3.20 (1.00–10.20)

Sham 26 10 38

Sherman andMassoud52

CRP 33 27 82 .06 CRP vs sham 24.75 (4.31–142.02)

Sham 13 2 15

Control 25 15 60

Soto Varela et al53,a Brandt-Daroffexercises

29 7 24 �.00001 Brandt-Daroffexercises vsCRP

0.13 (0.04–0.38)

LM 35 26 74 .15315b LM vs CRP 1.16 (0.42–3.18)

CRP 42 30 71

Salvinelli et al50 LM 40 32 80 �.01 LM vs control 6.67 (2.44–18.21)

Control 40 15 38

Radtke et al27,c Self-administeredCRP

37 35 95 �.001 Self-administeredLM vs self-administeredCRP

0.08 (0.02–0.38)

Self-administeredLM

33 19 58

Salvinelli et al51 LM 52 44 85 �.001 LM vs control 10.39 (4.04–26.74)

Flunarizine 52 30 58

Control 52 18 35

Tanimoto et al45,a CRP only 39 28 72 .048 Self-administeredCRP vs CRP

3.54 (1.02–12.30)

CRP and self-administeredCRP

40 36 90

von Brevern et al32 CRP 35 28 80 �.001 CRP vs sham 37.33 (8.75–159.22)

Sham 31 3 10

a Quasi-randomized controlled trial; standard treatment: canalith repositioning procedure (CRP).b No significance of comparison of liberatory maneuver (LM) and CRP.c Quasi-randomized controlled trial; standard treatment: self-administered CRP.




treatment and reduce health carecosts.

The liberatory maneuver was effec-tive in the treatment of PC BPPV, andthe quasi-RCTs found that the libera-tory maneuver was as effective as theCRP. However, RCTs need to be per-formed to determine whether theliberatory maneuver is more effec-tive for PC BPPV than a sham treat-ment and whether there is a correla-tion between the speed at which themaneuver is performed and the suc-cess of the maneuver.19

The self-administered CRP was moreeffective than the self-administeredliberatory maneuver in the treatmentof PC BPPV. More patients per-formed the self-administered libera-tory maneuver incorrectly than per-formed the self-administered CRPincorrectly. The Brandt-Daroff exer-cises had little or no effect on symp-tom resolution.53 Although this con-clusion is based on a singlerandomized study, the low successrate of the Brandt-Daroff exerciseswas consistent with the findings ofan earlier nonrandomized trial.26

Therefore, the self-administered CRPhas the highest reported treatmentefficacy, whereas the Brandt-Daroffexercises have the lowest reportedefficacy. For this reason, the Brandt-Daroff exercises are not recom-mended as an initial treatment ma-neuver. Patients should be physicallyand mentally screened to determinewhether they are good candidatesfor instruction in and correct perfor-mance of self-administered maneu-vers. To optimize outcomes, all pa-tients should receive illustratedinstructions with specific exercisesfor the affected ear, perform the ex-ercises under the supervision of anexperienced clinician, and be askedto perform the maneuver at the timeof follow-up to assess the accuracy ofperformance.27

Although these data demonstratethat the CRP, the liberatory maneu-ver, and the self-administered variantof the CRP are effective treatmentsfor PC BPPV,27,28,32,33,45,49–53,57 clini-cians must recognize that with bothof these maneuvers, there is achance (2.5%–6%) of causing a tran-sient worsening of the patient’s con-dition through a “canal conversion”from the PC to the lateral canal.45,67

Because of this possibility, cliniciansusing these maneuvers should beable to recognize and treat lateralcanal BPPV, although in most casesthe complication resolves on itsown. Patients performing self-administered treatments should beeducated about the possibility of acanal conversion. Unfortunately,RCTs regarding the treatment of lat-eral canal BPPV are not available.

Limitations of Study/Further InvestigationOnly 2 RCTs32,33 compared the effec-tiveness of the CRP and the effective-ness of a control in the treatment ofPC BPPV. The limited number ofstudies prevented us from includingthe articles in a quantitative synthe-sis or meta-analysis. The method-ological quality was low and theprobability of bias was high in stud-ies investigating the effectiveness ofthe liberatory maneuver and self-administered variants. Therefore, in-terpretation of the data should belimited. Randomized controlled tri-als investigating the effectivenessof the liberatory maneuver and self-administered variants need to beconducted.

The CRP was designed to use theforces associated with gravity totreat canalithiasis of the PC,18 andthe liberatory maneuver was de-signed to use both inertia and gravityto treat cupulolithiasis of the PC.25

The mechanism of BPPV may bedetermined on the basis of the char-acteristic nystagmus parameters oflatency to onset, duration, and am-

plitude. The nystagmus parameterswere not reported for the particlerepositioning maneuvers; therefore,correlations between the mecha-nism of BPPV and the outcome of themaneuvers could not be determined.Further research on this topic isneeded.

Two studies reported by the sameauthors attempted to evaluatequality-of-life measures before and af-ter the treatment of PC BPPV withthe liberatory maneuver.50,51 Infor-mation was insufficient to draw anyconclusions. Further studies assess-ing the quality of life before and afterthe successful treatment of PC BPPVwith particle repositioning maneu-vers are needed.

We did not qualitatively assess theoutcome of the patient’s report ofvertigo. The patient’s report of ver-tigo may be assessed during the DHTor with the patient’s daily routine (1week before the follow-up appoint-ment). The scales vary in that theyuse the frequency of reports of ver-tigo, the intensity of vertigo on ananalog scale of 1 to 10, and catego-rization of the resolution of BPPV onthe basis of a combination of subjec-tive symptoms and findings on theDHT. There was considerable vari-ability in the collection of the reportsof vertigo. The resolution of vertigowas reported at follow-up during po-sitional testing,32,49 within 1 week offollow-up during daily activities,33 atfollow-up with the completion of aquestionnaire (Vestibular DisordersActivities of Daily Living Scale68),50,51

through categorization of the resolu-tion of both symptoms and nystag-mus45,53 as first described by Epley,18

or no mention of symptoms.27,28,52

The development of a means for as-sessing the patient’s report of vertigois indicated.

ConclusionRandomized controlled trials sug-gested that the CRP was more effec-




tive than a control in the resolutionof BPPN in patients with PC BPPV.The evidence for the use of otherparticle repositioning maneuvers inthe treatment of PC BPPV was weak.There were limited numbers of stud-ies and no RCTs. Individual resultssuggested that the liberatory maneu-ver was more effective than a con-trol; there was no significant differ-ence in the effectiveness of theliberatory maneuver and the effective-ness of the CRP; the self-administeredCRP was more effective than the self-administered liberatory maneuver; andthe CRP administered together withthe self-administered CRP wasmore effective than the CRP admin-istered alone. The Brandt-Daroff ex-ercises were the least effective self-administered treatments. There wereno data on the effects of the particlerepositioning maneuvers on out-comes relevant to patients.

Dr Helminski, Dr Zee, and Dr Hain providedconcept/idea/research design and writing.Dr Helminski provided data collection andproject management. Dr Helminski and DrJanssen provided data analysis. Dr Hain pro-vided consultation (including review ofmanuscript before submission). The authorsacknowledge the assistance of MidwesternUniversity’s librarian, Rebecca Caton, MLIS,who assisted with the electronic literaturesearch, and Sandra Levi, PT, PhD, for herguidance in writing this systematic review.

A poster presentation of data from this studywas given at the Combined Sections Meet-ing of the American Physical Therapy Asso-ciation; February 9–12, 2009; Las Vegas,Nevada.

This article was submitted March 10, 2009,and was accepted December 21, 2009.

DOI: 10.2522/ptj.20090071

References1 von Brevern M, Radtke A, Lezius F, et al.

Epidemiology of benign paroxysmal posi-tional vertigo: a population based study.J Neurol Neurosurg Psychiatry. 2007;78:710–715.

2 Oghalai JS, Manolidis S, Barth JL, et al. Un-recognized benign paroxysmal positionalvertigo in elderly patients. OtolaryngolHead Neck Surg. 2000;122:630–634.

3 Fife D, FitzGerald JE. Do patients with be-nign paroxysmal positional vertigo receiveprompt treatment? Analysis of waitingtimes and human and financial costs asso-ciated with current practice. Int J Audiol.2005;44:50–57.

4 Schuknecht HF. Cupulolithiasis. Arch Oto-laryngol. 1969;90:765–778.

5 Hall SF, Ruby RR, McClure JA. The me-chanics of benign paroxysmal vertigo. JOtolaryngol. 1979;8:151–158.

6 Dix MR, Hallpike CS. The pathology,symptomatology, and diagnosis of certaincommon disorders of the vestibular sys-tem. Proc R Soc Med. 1952;45:341–354.

7 Bhattacharyya N, Baugh RF, Orvidas L,et al. Clinical practice guideline: benignparoxysmal positional vertigo. Otolaryn-gol Head Neck Surg. 2008;139(5 suppl 4):S47–S81.

8 Fife TD, Iverson DJ, Lempert T, et al. Prac-tice parameter: therapies for benign par-oxysmal positional vertigo (an evidence-based review): report of the QualityStandards Subcommittee of the AmericanAcademy of Neurology. Neurology. 2008;70:2067–2074.

9 Aw ST, Todd MJ, Aw GE, et al. Benignpositional nystagmus: a study of its three-dimensional spatio-temporal characteris-tics. Neurology. 2005;64:1897–1905.

10 Brandt T, Daroff RB. Physical therapy forbenign paroxysmal positional vertigo.Arch Otolaryngol. 1980;106:484–485.

11 Epley JM. New dimensions of benign par-oxysmal positional vertigo. OtolaryngolHead Neck Surg. 1980;88:599–605.

12 Herdman SJ. Treatment of benign parox-ysmal positional vertigo. Phys Ther. 1990;70:381–388.

13 Baloh RW, Jacobson K, Honrubia V. Hori-zontal semicircular canal variant of benignpositional vertigo. Neurology. 1993;43:2542–2549.

14 Halker RB, Barrs DM, Wellik KE, et al. Es-tablishing a diagnosis of benign paroxys-mal positional vertigo through the Dix-Hallpike and side-lying maneuvers: acritically appraised topic. Neurologist.2008;14:201–204.

15 Blau P, Shoup A. Reliability of a ratingscale used to distinguish direction of eyemovement using infrared/video ENG re-cordings during repositioning maneuvers.Int J Audiol. 2007;46:427–432.

16 Harada Y. Metabolic disorder, absorptionarea and formation area of the statoconia.J Clin Electron Microsc. 1982;18:1–18.

17 Lim DJ. Formation and fate of the otoco-nia: scanning and transmission electronmicroscopy. Ann Otol Rhinol Laryngol.1973;82:23–35.

18 Epley JM. The canalith repositioning pro-cedure: for treatment of benign paroxys-mal positional vertigo. Otolaryngol HeadNeck Surg. 1992;107:399–404.

19 Faldon ME, Bronstein AM. Head accelera-tions during particle repositioning ma-noeuvres. Audiol Neurootol. 2008;13:345–356.

20 Hain TC, Squires TM, Stone HA. Clinicalimplications of a mathematical model ofbenign paroxysmal positional vertigo.Ann N Y Acad Sci. 2005;1039:384–394.

21 Rajguru SM, Ifediba MA, Rabbitt RD.Three-dimensional biomechanical modelof benign paroxysmal positional vertigo.Ann Biomed Eng. 2004;32:831–846.

22 Hain TC, Helminski JO, Reis IL, Uddin MK.Vibration does not improve results of thecanalith repositioning procedure. ArchOtolaryngol Head Neck Surg. 2000;126:617–622.

23 Macias JD, Ellensohn A, Massingale S, Ger-kin R. Vibration with the canalith reposi-tioning maneuver: a prospective random-ized study to determine efficacy.Laryngoscope. 2004;114:1011–1014.

24 Motamed M, Osinubi O, Cook JA. Effect ofmastoid oscillation on the outcome of thecanalith repositioning procedure. Laryn-goscope. 2004;114:1296–1298.

25 Semont A, Freyss G, Vitte E. Benign par-oxysmal positional vertigo and provoca-tive maneuvers [in French]. Ann Otolar-yngol Chir Cervicofac. 1989;106:473–476.

26 Radtke A, Neuhauser H, von Brevern M,Lempert T. A modified Epley’s procedurefor self-treatment of benign paroxysmalpositional vertigo. Neurology. 1999;53:1358–1360.

27 Radtke A, von Brevern M, Tiel-Wilck K,et al. Self-treatment of benign paroxysmalpositional vertigo: Semont maneuver vsEpley procedure. Neurology. 2004;63:150–152.

28 Massoud EA, Ireland DJ. Post-treatment in-structions in the nonsurgical managementof benign paroxysmal positional vertigo. JOtolaryngol. 1996;25:121–125.

29 Roberts RA, Gans RE, DeBoodt JL, Lister JJ.Treatment of benign paroxysmal posi-tional vertigo: necessity of postmaneuverpatient restrictions. J Am Acad Audiol.2005;16:357–366.

30 Cakir BO, Ercan I, Cakir ZA, Turgut S. Ef-ficacy of postural restriction in treating be-nign paroxysmal positional vertigo. ArchOtolaryngol Head Neck Surg. 2006;132:501–505.

31 Baarsma EA. Vestibular testing in Mé-nière’s syndrome [in Dutch]. Acta Otorhi-nolaryngol Belg. 1979;33:254–263.

32 von Brevern M, Seelig T, Radtke A, et al.Short-term efficacy of Epley’s manoeuvre:a double-blind randomised trial. J NeurolNeurosurg Psychiatry. 2006;77:980–982.

33 Lynn S, Pool A, Rose D, et al. Randomizedtrial of the canalith repositioning proce-dure. Otolaryngol Head Neck Surg. 1995;113:712–720.

34 Imai T, Ito M, Takeda N, et al. Naturalcourse of the remission of vertigo in pa-tients with benign paroxysmal positionalvertigo. Neurology. 2005;64:920–921.

35 Lopez-Escamez JA, Gamiz MJ, Fernandez-Perez A, Gomez-Finana M. Long-termoutcome and health-related quality of lifein benign paroxysmal positional vertigo.Eur Arch Otorhinolaryngol. 2005;262:507–511.




36 Hilton M, Pinder D. The Epley (canalithrepositioning) manoeuvre for benign par-oxysmal positional vertigo. Cochrane Da-tabase Syst Rev. 2004;2:CD003162.

37 Teixeira LJ, Machado JN. Maneuvers forthe treatment of benign positional parox-ysmal vertigo: a systematic review. Braz JOtorhinolaryngol. 2006;72:130–139.

38 Woodworth BA, Gillespie MB, LambertPR. The canalith repositioning procedurefor benign positional vertigo: a meta-anal-ysis. Laryngoscope. 2004;114:1143–1146.

39 Olivo SA, Macedo LG, Gadotti IC, et al.Scales to assess the quality of randomizedcontrolled trials: a systematic review. PhysTher. 2008;88:156–175.

40 Chalmers TC, Celano P, Sacks HS, Smith HJr. Bias in treatment assignment in con-trolled clinical trials. N Engl J Med. 1983;309:1358–1361.

41 Moher D, Cook DJ, Eastwood S, et al. Im-proving the quality of reports of meta-analyses of randomised controlled trials:the QUOROM statement. Quality of Re-porting of Meta-analyses. Lancet. 1999;354:1896–1900.

42 Moher D, Cook DJ, Jadad AR, et al. Assess-ing the quality of reports of randomisedtrials: implications for the conduct ofmeta-analyses. Health Technol Assess.1999;3:i–iv, 1–98.

43 Schulz KF, Chalmers I, Hayes RJ, AltmanDG. Empirical evidence of bias: dimen-sions of methodological quality associatedwith estimates of treatment effects in con-trolled trials. JAMA. 1995;273:408–412.

44 Moher D, Dulberg CS, Wells GA. Statisticalpower, sample size, and their reporting inrandomized controlled trials. JAMA. 1994;272:122–124.

45 Tanimoto H, Doi K, Katata K, Nibu KI.Self-treatment for benign paroxysmal po-sitional vertigo of the posterior semicircu-lar canal. Neurology. 2005;65:1299–1300.

46 Longridge NS, Barber HO. Bilateral parox-ysmal positioning nystagmus. J Otolaryn-gol. 1978;7:395–400.

47 Portney LG, Watkins MP. Foundations ofClinical Research: Applications to Prac-tice. 3rd ed. Upper Saddle River, NJ: Pear-son Prentice Hall; 2009.

48 Sherrington C, Herbert RD, Maher CG,Moseley AM. PEDro: a database of random-ized trials and systematic reviews in phys-iotherapy. Man Ther. 2000;5:223–226.

49 Froehling DA, Bowen JM, Mohr DN, et al.The canalith repositioning procedure forthe treatment of benign paroxysmal posi-tional vertigo: a randomized controlled tri-al. Mayo Clin Proc. 2000;75:695–700.

50 Salvinelli F, Casale M, Trivelli M, et al. Be-nign paroxysmal positional vertigo: a com-parative prospective study on the efficacyof Semont’s maneuver and no treatmentstrategy. Clin Ter. 2003;154:7–11.

51 Salvinelli F, Trivelli M, Casale M, et al.Treatment of benign positional vertigo inthe elderly: a randomized trial. Laryngo-scope. 2004;114:827–831.

52 Sherman D, Massoud EA. Treatment out-comes of benign paroxysmal positionalvertigo. J Otolaryngol. 2001;30:295–299.

53 Soto Varela A, Bartual Magro J, SantosPérez S, et al. Benign paroxysmal vertigo: acomparative prospective study of the effi-cacy of Brandt and Daroff exercises, Se-mont and Epley maneuver. Rev LaryngolOtol Rhinol (Bord). 2001;122:179–183.

54 Angeli SI, Hawley R, Gomez O. Systematicapproach to benign paroxysmal positionalvertigo in the elderly. Otolaryngol HeadNeck Surg. 2003;128:719–725.

55 Asawavichianginda S, Isipradit P, Snid-vongs K, Supiyaphun P. Canalith reposi-tioning for benign paroxysmal positionalvertigo: a randomized, controlled trial.Ear Nose Throat J. 2000;79:732–734,736 –737.

56 Blakley BW. A randomized, controlled as-sessment of the canalith repositioning ma-neuver. Otolaryngol Head Neck Surg.1994;110:391–396.

57 Califano L, Capparuccia PG, Di Maria D,et al. Treatment of benign paroxysmal po-sitional vertigo of posterior semicircularcanal by “Quick Liberatory Rotation Ma-noeuvre.” Acta Otorhinolaryngol Ital.2003;23:161–167.

58 Cavaliere M, Mottola G, Iemma M. Benignparoxysmal positional vertigo: a study oftwo manoeuvres with and without beta-histine. Acta Otorhinolaryngol Ital. 2005;25:107–112.

59 Chang AK, Schoeman G, Hill M. A random-ized clinical trial to assess the efficacy ofthe Epley maneuver in the treatment ofacute benign positional vertigo. AcadEmerg Med. 2004;11:918–924.

60 Cohen HS, Kimball KT. Effectiveness oftreatments for benign paroxysmal posi-tional vertigo of the posterior canal. OtolNeurotol. 2005;26:1034–1040.

61 Li JC. Mastoid oscillation: a critical factorfor success in canalith repositioning pro-cedure. Otolaryngol Head Neck Surg.1995;112:670–675.

62 Munoz JE, Miklea JT, Howard M, et al.Canalith repositioning maneuver for be-nign paroxysmal positional vertigo: ran-domized controlled trial in family practice.Can Fam Physician. 2007;53:1049–1053,1048.

63 Serafini G, Palmieri AM, Simoncelli C. Be-nign paroxysmal positional vertigo of pos-terior semicircular canal: results in 160cases treated with Semont’s maneuver.Ann Otol Rhinol Laryngol. 1996;105:770–775.

64 Sridhar S, Panda N, Raghunathan M. Effi-cacy of particle repositioning maneuver inBPPV: a prospective study. Am J Otolar-yngol. 2003;24:355–360.

65 Wolf M, Hertanu T, Novikov I, Kronen-berg J. Epley’s manoeuvre for benign par-oxysmal positional vertigo: a prospectivestudy. Clin Otolaryngol Allied Sci. 1999;24:43–46.

66 Yimtae K, Srirompotong S, SrirompotongS, Sae-Seaw P. A randomized trial of thecanalith repositioning procedure. Laryn-goscope. 2003;113:828–832.

67 Herdman SJ, Tusa RJ. Complications of thecanalith repositioning procedure. ArchOtolaryngol Head Neck Surg. 1996;122:281–286.

68 Cohen HS, Kimball KT. Development ofthe Vestibular Disorders Activities of DailyLiving Scale. Arch Otolaryngol Head NeckSurg. 2000;126:881–887.




doi: 10.2522/ptj.20090071Originally published online March 25, 2010

2010; 90:663-678.PHYS THER. and Timothy Carl HainJanet Odry Helminski, David Samuel Zee, Imke JanssenVertigo: A Systematic Reviewthe Treatment of Benign Paroxysmal Positional Effectiveness of Particle Repositioning Maneuvers in

References

http://ptjournal.apta.org/content/90/5/663#BIBLfor free at: This article cites 67 articles, 14 of which you can access

Cited by

http://ptjournal.apta.org/content/90/5/663#otherarticles

This article has been cited by 8 HighWire-hosted articles:

Information Subscription http://ptjournal.apta.org/subscriptions/

Permissions and Reprints http://ptjournal.apta.org/site/misc/terms.xhtml

Information for Authors http://ptjournal.apta.org/site/misc/ifora.xhtml

at VA Medical CenterRoom 1100 on March 28, 2013http://ptjournal.apta.org/Downloaded from
http://ptjournal.apta.org/content/90/5/663#BIBLhttp://ptjournal.apta.org/content/90/5/663#otherarticleshttp://ptjournal.apta.org/

Documents

Originally published online March 25, 2010 BPPV 2010.pdflithiasis,5 in which the otoconia freely sediment in the canals. Reori-entation of the canals causes the oto-conia to move to