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Three Part Question

In [a patient presenting to the Emergency Department with acute benign positional vertigo] is the [Epley maneuver better than placebo maneuver] in [reducing symptoms of vertigo]?

Clinical Scenario

You are the Emergency Department physician seeing a 35 year old woman who presents with extreme, short bursts of dizziness. Upon further questioning and physical exam, you find out that she is experiencing vertigo several seconds after moving her head, the vertigo resolves when her head is kept still and she has a positive Dix-Hallpike test. She did not experience any prodromal symptoms prior to the onset of her vertigo. You are confident that she has benign positional vertigo and recall the Epley Maneuver as a way to help treat her symptoms. Before performing the Epley Maneuver on the patient, you wonder if there has been any proof that the Epley Maneuver actually works in reducing the symptoms of acute benign positional vertigo.

Search Strategy

Medline 1966-06/05 using the OVID interface, Cochrane Library (2005)
[(exp vertigo/ or vertigo.mp) AND (epley.mp or canalith repositioning.mp or exp physical therapy techiques/)]. LIMIT to human AND English.
[(exp vertigo/ or vertigo.mp) AND (epley.mp or canalith repositioning.mp or exp physical therapy techniques/)]. LIMIT to human AND English.

Search Outcome

238 papers were found of which 1 was a meta-analysis of 15 other papers (randomized trials). Another paper was a recent RCT which examined the Epley maneuver in ED patients presenting with acute BPV. 236 papers were discarded as either irrelevant or of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hilton,M. Pinder,D. 2005 United Kingdom	Adults (age greater than 16 years) presenting to outpatient clinics or emergency department with clinical diagnosis of benign paroxysmal positional vertigo. The clinical diagnosis must state that the paitent had a positive Dix-Hallpike positional test with clear and classical features of positional nystagmus.	Meta-analysis of 15 papers (randomized trials), only three studies were deemed worthy for review (all prospective randomized controlled trials). These studies addressed the efficacy of the Epley maneuver against a sham maneuver or control group by comparing the proportion of subjects in each group who had complete resolution of their symptoms, and who converted from a positive to negative Dix-Hallpike test.	Proportion of patients improved by each intervention and conversion of a	Statistically significant difference in symptom resolution in favor of the Epley group. Pooled data yielded an odds ratio of 4.22 (95% C.I. 1.96-9.08) in favor of Epley maneuver. Statistically significant difference in conversion from a positive to a negative Hallpike maneuver in favor of the Epley group. Pooled data yielded an odds ratio of 5.12 (95% C.I. 2.30-11.39) in favor of the Epley maneuver.	Long term follow up was lacking in all three included studies (limited to two weeks to a month). Therefore it is unknown if the Epley maneuver provides permanent relief of BPV or just temporary remission of symptoms. Study groups were small in the included studies (36, 50 and 58). The randomisation was not explicit in one of the included studies (Froehling 2000).

Comment(s)

The evidence for the effectiveness of the Epley maneuver in treating BPV is limited in that it is based on the results of four small randomized controlled trials with relatively short follow up. These studies show the Epley maneuver to be statistically significant in reducing patient's symptom of vertigo and/or conversion from a positive to negative Dix-Hallpike test, when compared to a sham procedure or untreated controls.

Clinical Bottom Line

The Epley maneuver is a safe and simple bedside maneuver that appears to be more efficacious than a placebo maneuver in the treatment of acute benign positional vertigo among Emergency Department patients.

References

1. Chang AK. Schoeman G. Hill M. A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo. Academic Emergency Medicine 11(9):918-24, 2004 Sep.
2. Hilton,M. Pinder,D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews The Cochrane Collaboration, Volume (3), 2005, [no page #]