The Epley maneuver is an exercise you can do at home to relieve dizziness caused by benign paroxysmal positional vertigo BPPV. BPPV is caused by a problem with the inner ear. Calcium crystals called canaliths can end up in the semicircular canals. If these crystals become dislodged and move around, they can cause the sensation that the world is spinning or moving, also known as vertigo. The Epley maneuver, however, can dislodge these crystals and remove them from the semicircular canals.
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Timothy C. Hain, MD Page last modified: May 9, The Epley maneuver, named after Dr. John Epley, is both intended to move debris or "ear rocks" out of the sensitive part of the ear posterior canal to a less sensitive location. It is also sometimes called the "canalith repositioning maneuver" or CRP.
The Epley maneuver takes about 15 minutes to complete. The Epley consists of sequential movement of the head into four positions positions B-D , staying in each position for roughly 30 seconds.
The positions of the Epley are illustrated in figure 1. 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. Comment: Massoud and Ireland stated that post-treatment instructions were not necessary.
While we respect these authors, at this writing , we still feel it best to follow the procedure recommended by Epley. While some authors advocate use of vibration in the Epley maneuver, we have not found this useful in a study of our patients Hain et al, Use of an antiemetic prior to the maneuver may be helpful if nausea is anticipated. Ondansetron is the one we stock in our practice for this. Some authors suggest that position 'D' in the figure above is not necessary e.
Helen Cohen as in Cohen et al. In our opinion, this is a mistake as mathematical modeling of BPPV suggests that position 'D' is the most important position Squires et al, Mathematical modeling also suggests that position 'C' is probably not needed. In our opinion, position 'C' has utility as it gives patients a chance to regroup between position 'B' and 'D'.
Before we get going with this discussion -- note that there is really only one geometric way to roll rocks out of a circle, and thus all of these maneuvers are just variants on the same thing the Epley maneuver. Also note that there are many "home treatment" maneuvers published Furman and Hain, The Semont maneuver -- this is discussed in detail elsewhere, but it is very clear that it is just another way to get the head positioned so that gravity moves otoconia out of the posterior canal.
There are both clinic and home versions. We don't use it much in our clinic. The "Gans" maneuver. This is another little used treatment maneuver, called the "Gans maneuver by it's inventor R. Gans, Ph. It incorporates the head orientations to gravity of "B" and "D" in the Epley figure above, using the body positions of the Semont maneuver.
It leaves out position 'C' in the figure above. We often recommend the home-Epley to our patients who have a clear diagnosis. This procedure seems to be even more effective than the in-office procedure, perhaps because it is repeated every night for a week. The method for the left side is performed as shown on the figure to the right.
One stays in each of the supine lying down positions for 30 seconds, and in the sitting upright position top for 1 minute. Typically 3 cycles are performed just prior to going to sleep. It is best to do them at night rather than in the morning or midday, as if one becomes dizzy following the exercises, then it can resolve while one is sleeping. The mirror image of this procedure is used for the right ear. There are several problems with the "do it yourself" method.
If the diagnosis of BPPV has not been confirmed, one may be attempting to treat another condition such as a brain tumor or stroke with positional exercises -- this is unlikely to be successful and may delay proper treatment. A second problem is that the home-Epley requires knowledge of the "bad" side. Sometimes this can be tricky to establish. Complications such as conversion to another canal see below can occur during the Epley maneuver, which are better handled in a doctor's office than at home.
Finally, occasionally during the Epley maneuver neurological symptoms are provoked due to compression of the vertebral arteries. In our opinion, it is safer to have the first Epley performed in a doctors office where appropriate action can be taken in this eventuality.
The "Foster" maneuver. In , Dr. Carol Foster reported another self-treatment maneuver for posterior canal BPPV, that she subsequently popularized with online videos on Youtube. In this maneuver, using the illustrations above that she published in her article, one begins with head up, then flips to upside down, comes back up into a push-up position with the head turned laterally, and then back to sitting. Biomechanically, this is just another way to get a series of positions similar to the Epley maneuver.
It appears to require a bit more strength and flexibility and strength than the self-Epley maneuver reported by Radke , or for that matter, nearly any of the other maneuvers. Of course, it doesn't really matter how you get your head into these positions - -as they all do the same thing. Foster, in her article, states that her maneuver is not as effective as the regular Epley maneuver, but patients prefer it anyway.
Although it looks like a good arm workout, to get rid of BPPV, we don't see any particular reason to use or not use Dr. Foster's maneuver over any of the other recent home treatment BPPV maneuvers i. We don't recommend the Brandt-Daroff exercises however.
Many patients have been reported in controlled studies. A metanalysis published in indicated that there is very good evidence that the Epley maneuver CRP is effective Helminski et al, See here for the details. However, as they are doing almost the same thing as the other maneuvers do to the head, they should. For this reason, in persons who have continued dizziness, a follow-up visit is scheduled and another nystagmus test with video-Frenzel goggles is done.
When all maneuvers have been tried, the diagnosis is clear, and symptoms are still intolerable, surgical management posterior canal plugging may be offered. This is exceedingly rare. Occasional patients travel to a facility where a device is available to position the head and body to make the maneuvers more effective.
See this page for more information about this option. BPPV often recurs. If BPPV recurs, in our practice we usually retreat with one of the maneuvers above.
Learn about our expanded patient care options for your health care needs. The home Epley maneuver is a type of exercise help that helps to treat the symptoms of benign paroxysmal positional vertigo BPPV. You can do this exercise at home. BPPV is caused by a problem in your inner ear. Your semicircular canals are found inside your ear. They detect motion and send this information to your brain. The utricle is a nearby part of the ear.