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Three Part Question

In [adult patients diagnosed with posterior canal BPPV] is [the Epley manoeuvre more effective than the Semont] at [reducing symptoms]?

Clinical Scenario

You have reviewed a 45 year old woman complaining of vertigo on head movement with no other concerning features. She has a positive Dix-Hallpike test and you diagnose BPPV. In teaching today you were shown the Semont manoeuvre, you wonder if this manoeuver or the Epley manoeuvre would be more effective in treating her.

Search Strategy

MEDLINE 1947-11/2015 & EMBASE using the OVID interface


[{(Semont OR liberatory) AND (Epley OR reposition$)} LIMIT to (English)]

Search Outcome

Medline search identified 75 papers including 1 after review of references. 4 of these papers proved to be relevant, one of which was a metaanalysis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
MP Hilton DK Pinder 2014 England	11 RCTs (2 directly applicable)	Metaanalysis	Negative Dix-hallpike test at 7 days post treatment	No difference between Epley and Semont manoeuvre. Pooled Odds Ratio 0.78 (95%CI 0.32 to 1.88)	Small number of patients trialled. The RCT’s were variable in the description of their randomisation. No details on allocation concealment.
			Treatment side effects	Both papers report no significant different in rates of nausea.
J. Lee et al 2014 Korea	99 adults with positional vertigo and positive Dix-Hallpike tests	RCT	Resolution of vertigo and negative Dix Hallpike test (20 mins after first manoeuvre)	Epley 23 patients (63.9%) vs Semont 12 patients (37.5%) vs Sham 12 patients (38.7%) (p<0.05)	5 of the 14 institutes had no previous experience with the Semont manoeuvre. All of the sites were experienced in the Epley manoeuvre. Small number of participants and no evidence of any power calculation. May be underpowered to show any meaningful statistical difference between all 3 groups.
			Resolution of vertigo and negative Dix Hallpike test (20 mins after repeated manoeuvre)	Epley 30 patients (83.3%) vs Semont 21 patients (65.6%) vs Sham 16 patients (51.6%). (p<0.05)
			Outcome after 1 day	Epley 33 patients (88.9%) vs Semont 19 patients (59.3%) vs Sham 11 patients (35.5%). (p<0.001)
			Outcome after 1 week	Epley 34 patients (94.4%) vs Semont 23 patients (71.9%) vs Sham 24 patients (77.4%). (p<0.05)
E. Anagnostou et al 2014 Greece	102 adults with positive Dix-Hallpike tests (>2 months)	RCT	Treatment success – A negative Dix-Hallpike test independent from patients’ report of vertigo. Assessed on same day 2-5 hours after manoeuvre.	Both Semont and Epley were successful in 67% and 76% of cases, respectively. This difference was not significant.	Patients were not properly randomised - allocated in a very predictable way. Outcome assessment undertaken by the treating physician thus not blinded. Follow up period was short and will likely underestimate treatment success.
			Posterior to horizontal canal switch post manoeuvre.	No conversions in the Semont group. 4 of 51 Epley cases converted (p<0.05).
E. Massoud D. Ireland 1996 Canada	96 adults with positive Dix-Hallpike test	RCT	Symptom resolution and negative Dix-Hallpike test	Epley 93.4% vs 92%. No statistically significant difference	There is lack of information on the study design, including how randomisation was undertaken, how the patients were identified and who obtained the results. Results were presented as a cumulative resolution instead of resolution after one manoeuvre and then the second.

Comment(s)

The papers comparing the Semont and Epley manoeuvres are generally of low quality, a feature highlighted in the metaanalysis. The evidence does conclude however that both manoeuvres are superior to no intervention. Both techniques are relatively simple to perform. The Semont manoeuver does require fewer steps and as a result less physical movement of the patient. With the exception of the Lee et al paper, all papers concluded that both manoeuvres had similar efficacy. Lee et al concluded that the Epley was superior to the Semont. This paper did show bias; their conclusion may be explained by the fact that not all of the featured training centres were familiar with the Semont manoeuver. It was also shown that both manoeuvres appear to have similar incidence of side effects. One exception was canal switching. It appeared that after performing the Epley manoeuvre there was the potential to switch from posterior canal BPPV to other forms which would require further, different repositioning techniques to treat. A recent review by Fife et al (1), set in the emergency department, contextualises the importance of these manoeuvers. It effectively demonstrates their practicality and significant cost effectiveness in the acute care setting.

Clinical Bottom Line

Both the Semont and Epley manoeuvers are equally effective at resolving posterior canal BPPV.

References

1. M. Hilton, D. Pinder The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo Cochrane Database Syst Rev 2014;12:CD003162
2. J. Lee et al A Multicenter Randomized Double-Blind Study: Comparison of the Epley, Semont, and Sham Maneuvers for the Treatment of Posterior Canal Benign Paroxysmal Positional Vertigo Audiology & Neurotology 2014;19:336–341
3. E. Anagnostou et al Canal conversion after repositioning procedures: comparison of Semont and Epley maneuver Journal of neurology 2014;261:866-869
4. E. Massoud, D. Ireland Post-treatment instructions in the nonsurgical management of Benign Paroxysmal Positional Vertigo The journal of otolaryngology 1996;25:121-125
5. T. Fife, M. Brevern Benign Paroxysmal Positional Vertigo in the acute care setting Neurologic clinics 2015;33(3):601-617