Epley maneuver how long to work

According to Kahraman et al, , there is no difference in success rate between short maneuvers i. Nevertheless, we think it is more logical to use short duration for strong nystagmus, and longer duration for weak nystagmus or refractory cases. There may not be much nystagmus in position B 2.

When performing the Epley maneuver, caution is advised should neurological symptoms for example, weakness, numbness, visual changes other than vertigo occur. Occasionally such symptoms are caused by compression of the vertebral arteries Sakaguchi et al, , and if one persists for a long time, a stroke could occur. If the exercises are being performed without medical supervision, we advise stopping the exercises and consulting a physician.

If the exercises are being supervised, given that the diagnosis of BPPV is well established, in most cases we modify the maneuver so that the positions are attained with body movements rather than head movements. After the Epley, you should provide your patient with the instructions below, which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear.

Wait for 10 minutes after the maneuver is performed before going home. This is to avoid "quick spins," or brief bursts of vertigo as debris repositions itself immediately after the maneuver.

Don't drive yourself home. Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright a 45 degree angle. This is most easily done by using a recliner chair or by using pillows arranged on a couch see figure 3. During the day, try to keep your head vertical. You must not go to the hairdresser or dentist.

No exercise which requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head back. Shampoo only under the shower. Some authors suggest that no special sleeping positions are necessary Cohen, ; Massoud and Ireland, We, as do others, think that there is some value Cakir et al, For at least one week, avoid provoking head positions that might bring BPPV on again.

Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the beauty parlor, dentist's office, and while undergoing minor surgery.

Try to stay as upright as possible. Exercises for low-back pain should be stopped for a week. No "sit-ups" should be done for at least one week and no "crawl" swimming. Breast stroke is OK. Also avoid far head-forward positions such as might occur in certain exercises i. Do not start doing the Brandt-Daroff exercises immediately or 2 days after the Epley or Semont maneuver, unless specifically instructed otherwise by your health care provider.

At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can't fall or hurt yourself. Let your doctor know how you did. The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary.

Long-term follow-up of patients [ 8 ]. Another meta-analysis came to the same conclusions [ 9 ]. No serious adverse effects have been reported. Although most clinical trials on the effectiveness of this maneuver have taken place in specialized clinics, one study conducted in a primary care center demonstrated that trained GPs achieved the same results as the specialists in terms of D-H test turning negative. However, this study could not prove the subjective improvement of the patients compared to the control group [ 13 ].

Several authors emphasize the need for more research to be performed in the primary care setting. Out of the patients studied, only 2 cases the 2 submitted by ENT specialists had undergone the D-H maneuver to reach the diagnosis [ 15 ].

A study conducted in Spain found that the average duration between the onset of symptoms and initiation of treatment with canalith repositioning maneuvers in a specialized ENT center was 20 weeks and that only 1 patient out of 60 was correctly diagnosed as BPPV [ 16 ].

A systematic review also recommends that more research be performed and emphasizes that such investigation should include different specialists, other than otolaryngologists or neurologists, such as GPs [ 17 ]. Several other studies have proved that the combination of betahistine and repositioning maneuvers improve outcomes, in comparison to maneuvers alone [ 19 , 20 ] but its use for BPPV remains controversial [ 21 ].

Our clinical trial will be conducted in a primary care setting, and will study the condition at its earliest stages, when patients are more likely to attend our practices, and where the literature is less conclusive.

In addition, response to treatment will be evaluated at one month and at one year after inclusion in the study. Definition of clinical improvement will include negativization of the D-H maneuver, improvement in the subjective perception of vertigo, quality of life and amount of betahistine tablets that the patients report to have taken.

We will analyze whether there is a statistically significant clinical improvement in the intervention group in comparison to the control group in terms of:.

Days of temporary disability due to vertigo or other causes, recorded on the electronic medical record. This is a controlled randomized clinical trial, which will be conducted by GPs who will have previously received a two-hour training to perform the repositioning maneuvers under the supervision of an ENT specialist. Patients will be reassessed one week, one month, and one year after the first visit by a different GP from the one who performed the first visit, in order to accomplish blinding of both study participants and personnel.

Two urban primary care centers which provide care for a population of approximately 49, people. All patients with newly diagnosed BPPV, who attend our two primary care centers, will be potential participants in our clinical trial.

Patients will be systematically recruited with the collaboration of the 26 GPs who work at the two participant primary care centers. Eligible participants will be informed of the possibility to take part in the trial and will be supplied with written information about the study. Those who accept to participate in the study will be given an appointment for the baseline visit, preferably within a week and no longer than ten days after. The recruitment period is expected to last two years Figure 1.

Patients aged 18 years and older who attend our primary care centers, with suspected diagnosis of BPPV, and present vertigo or nystagmus following the D-H maneuver. All other causes of vertigo should be ruled out through clinical history assessment and review of the electronic medical record. Written informed consent will be obtained from all subjects, of both the intervention group and the control group, prior to their inclusion in the study. The exclusion criteria, which will be detected through the clinical history, physical examination and review of the electronic medical record, are:.

Other causes which may hinder the understanding of the objectives and methodology of the trial language, low educational level, and so on. Accepting an alpha risk of 0. This sample size also enables us to evaluate 1-point clinical improvement in the intervention group compared to the control group, assuming a standard deviation of 1.

We estimated a recurrence hazard ratio of 0. All the relevant information will be presented again to the participants at the baseline visit and the opportunity to ask any questions they may deem appropriate will be offered. After signing the informed consent, inclusion and exclusion criteria will be reviewed again and BPPV will be confirmed by the clinical history and physical examination D-H test positive to the right or the left at the first visit of the study.

Those who meet the following three criteria: presenting no exclusion criteria, all inclusion criteria met, and signed informed consent, will be randomized to the intervention group or the control group. Patients will be assigned to the intervention or control group using the randomization sequence list prepared in advance by the study statistician.

The responsibility for guarding and supervising the randomization list will rest on a staff member of our primary care center who is not directly involved in the trial. GPs will contact the randomization list guardian by telephone in order to find out the randomization number and to which study arm the participant has been assigned. These data will not be recorded in either the case report forms or in the database.

Only the study statistician will be allowed access to this information. Follow-up visits will be carried out by a different GP from the one who performed the first visit in order to accomplish blinding of both study participants and personnel. A paper case report form CRF has been designed to record all the data from the four visits performed during the trial.

The paper case report form will be reviewed after a pilot test. All participants will have their electronic medical record reviewed. An accurate medical history will be obtained and a thorough physical examination will be performed. The information collected will include: age, sex, educational level, profession and employment status, date of onset and duration of the symptoms from onset to visit 1, previous history of BPPV episodes total number , past medical history of other conditions viral infection in the previous four weeks, head trauma, neck osteoarthritis or neck pain , pharmacological treatment, specially for the treatment of anxiety, depression or hypertension.

During the physical examination we will evaluate blood pressure in the sitting and standing positions, heart rate, color of skin and mucous membranes, cardiac and respiratory auscultation, basic neurological examination cranial nerves, visual fields, brainstem and muscle stretch reflexes, posture, balance and coordination tests test station, tests for dyssynergia and dysmetria, and gait , otoscopy and D-H maneuver to the left and right to detect the presence of nystagmus or vertigo [ 22 ].

If the examination suggests involvement of the anterior or lateral semicircular canals or presence of a central vertigo nystagmus that lasts more than a minute, vertical nystagmus or alternant , the patient will be excluded from the study and referred to a specialist. This result will be subdivided into: a vertigo with nystagmus or b vertigo without nystagmus [ 23 ]. The DHI-S is a item self-assessment inventory effectively used to evaluate the perceived degree of disability caused by vertigo, dizziness and instability and its impact on daily life activities.

It also identifies physical, functional, and emotional conditions related to balance disorders [ 24 ]. Moreover, most patients may improve spontaneously after a month, regardless of which group they were assigned.

The maneuver consists of five sequential positions of the head and body, performed with the aim to move the displaced canaliths from the semicircular canal back to the utricle where they no longer cause symptoms.

There is some controversy over whether postural restrictions for a few days after this procedure are beneficial for the patient and can improve outcomes [ 26 ].

However, we have decided not to include these restrictions in our study as they are poorly tolerated and can hamper the comparability between groups [ 27 ]. A sham maneuver, which will consist of laying the patient with the head tilted on the affected side for five minutes, as described in the literature [ 17 , 23 ], will be performed only on the first visit. The second visit will take place 1 week after visit 1. Visits 3 and 4 will be performed 1 month, and 1 year after visit 1, respectively.

Data will be analyzed in accordance with the CONSORT guide for cluster randomized trials, and all analyses will be performed on an intent-to-treat basis [ 28 ]. Firstly, the intervention group and control group will be analyzed for baseline comparability according to the baseline variables. Descriptive statistics of all studied variables will be presented in contingency tables.

A multivariate linear regression model will be conducted to evaluate change in the Likert scale and quality of life inventory DHI-S , objectives 5 and 6 ; and a Poisson or Binomial negative distribution for of outcome variables in case of over-dispersion will be used to compare number of vertigo episodes, number of tablets consumed, days of temporary disability and days with symptoms objectives 3, 7 and 8.

The estimated number of observers will be 10 to Data will be introduced into a SPSS version Descriptive analysis, and statistical hypothesis testing, will also be conducted with the SPSS version The level of statistical significance will be set at 0.

All known potential confounding factors will be measured at the beginning of the study and comparison between the control and the intervention groups will be carried out adjusted for these known confounders. Obtaining a signed informed consent from the participants will be a mandatory requirement before study initiation.

Study information will be provided verbally and in writing to all participants. Participants in the study will have the opportunity to resolve any doubts about study details. Our study aims to demonstrate the effectiveness of repositioning maneuvers in the treatment of posterior canal BPPV, performed by trained GPs in the primary care setting.

We found that only one study had been conducted in primary care, and it proved that this treatment was effective in the first week, regarding negativization of D-H test, but not in terms of subjective improvement of patients [ 18 ]. This study only evaluated patients from baseline to week 1. In our study we will reassess patients one week, one month and one year after the first visit. Frentzel glasses a diagnostic tool to evaluate nystagmus were not used in the study in order to achieve a more realistic approach in the diagnosis of BPPV in primary care.

Therefore, study patients who only experience vertigo and do not present nystagmus during the D-H test will not be excluded from inclusion as performed in other studies [ 29 ]. This factor, however, will be accounted for by evaluating these patients separately. Betahistine administration during the course of treatment can speed up the recovery of these patients [ 25 , 26 ] and may also be useful to evaluate the results of the study.

To avoid bias in our trial, all patients from both groups intervention and control , will be prescribed betahistine 8 mg on a pro re nata PRN basis, up to three times a day until improvement of symptoms. Each participant will be given a notebook in order to record the number of tablets taken between visits.

From an ethical point of view, we believe that leaving patients untreated, apart from the sham maneuver is an arguable point. You may also have upset stomach nausea and vomiting. Often BPPV happens without any known cause. Sometimes there is a cause. Causes of BPPV can include:. Other problems with the balance-related part of your inner ear vestibular system. These can include nerve inflammation vestibular neuronitis. The home Epley maneuver is safe and inexpensive.

It often works well to treat the symptoms of BPPV. Your healthcare provider may advise the home Epley maneuver if your health history and physical exam support that you have BBPV. Your provider may also advise that you see a vestibular therapist for treatment. Your provider may first do the original Epley maneuver in their office. They may teach you the home Epley maneuver. It may also be helpful to know how to do this exercise if your BPPV comes back after a few months or years.

This exercise is safe. It may be helpful to have someone at home with you while you go through the movements.

This can give you peace of mind in case your vertigo gets worse in the middle of the treatment. People with health conditions that limit their ability to move may not be able to do the home Epley maneuver safely. These issues can include neck or back disease, vascular conditions, and retinal detachment. Ask your healthcare provider if the exercise is safe for you. You can do the home Epley maneuver on a bed.

You start by sitting on the bed. You need to have a pillow in place so that when you lie back it will be under your shoulders. You may find it helpful to watch a video of the exercise first. Or you may want to read a brochure with pictures. Your healthcare provider will tell you how often to do this exercise. They may ask you to do it 3 times a day until your symptoms have been gone for 24 hours.

Your provider will also tell if your right or left ear is causing your symptoms. Quickly lie back, keeping your head turned. Your shoulders should now be on the pillow, and your head should be reclined.