LEAP

LINKING EVIDENCE AND PRACTICE

Effectiveness of the Canalith Repositioning Procedure in
the Treatment of Benign Paroxysmal Positional Vertigo
Janet O. Helminski
<LEAP> highlights the findings and
application of Cochrane reviews and
other evidence pertinent to the
practice of physical therapy. The
Cochrane Library is a respected
source of reliable evidence related to
health care. Cochrane systematic
reviews explore the evidence for and
against the effectiveness and appropriateness of interventionsmedications, surgery, education, nutrition,
exerciseand the evidence for and
against the use of diagnostic tests for
specific conditions. Cochrane reviews
are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of
research studies published in the scientific literature.1 Each article in this
PTJ series summarizes a Cochrane
review or other scientific evidence on
a single topic and presents clinical
scenarios based on real patients or
programs to illustrate how the results
of the review can be used to directly
inform clinical decisions. This article
focuses on an adult patient with
benign paroxysmal positional vertigo. Can a canalith repositioning
procedure help this patient?

Find the <LEAP> case archive at

http://ptjournal.apta.org/cgi/
collection/leap.

October 2014

Benign paroxysmal positional vertigo (BPPV) presents as brief periods

of vertigo experienced with a
change in the position of a persons
head relative to gravity. Benign paroxysmal positional vertigo is a
mechanical disorder of the inner ear
and is caused by abnormal stimulation of 1 or more of the 3 semicircular canals (Fig. 1). The otoconia from
the utricle dislodge and settle within
1 of the 3 semicircular canals, changing the fluid-filled canal dynamics
from detecting rotation of the canals
to detecting gravitation forces on the
head. With BPPV, changing the
plane of the involved canal relative
to gravity causes debris to settle to
the lowest part of the canal, changing the fluid pressure across the cupula, deflecting the hair cells, and generating the characteristic ocular
nystagmus with associated vertigo.
There are 3 mechanisms of BPPV,
the most common being debris
within the long arm of the canal; this
mechanism is called canalithiasis.2
Debris also may be found in the short
arm of the canal3 or attached to the
cupula, weighting the membrane;
this mechanism is called cupulolithiasis.3 The canal most commonly
involved is the posterior semicircular canal.4
The diagnosis of BPPV is based on
history and findings on positional
testing.5,6 Patients who complain of
vertigo with rolling in bed or getting
out of bed are 4.3 times more likely
to have BPPV.7 The Dix-Hallpike
test8 and the side-lying test9 are the
standard tests5,6 for evaluating posterior canal BPPV. A comparison of the
Dix-Hallpike test and the side-lying
test revealed no significant difference between the 2 techniques.9

Frenzel lenses or video oculography

should be used to prevent the suppression of ocular nystagmus. The
diagnostic criteria for posterior canal
BPPV are vertigo associated with the
characteristic nystagmustorsional
(superior pole of the eye directed
toward the lowermost ear [ie, the
involved ear]) and upbeating,10 with
a latency of 1 to 45 seconds before
onset1113 and a duration of less than
60 seconds14and fatigue with
repeated positioning.14 For the DixHallpike test, the estimated sensitivity is 79% (95% confidence interval
[95% CI]6594), and the specificity
is 75% (95% CI33100); for the
side-lying test, the estimated sensitivity is 90% (95% CI79 100),
and the specificity is 75% (95%
CI34 100).15
Once identified, posterior canal
BPPV may be effectively treated with
a particle repositioning maneuver,
such as the canalith repositioning
maneuver (CRP) described by
Epley.16 The CRP is a series of 4 head
positions designed to use the effects
of gravity to treat canalithiasis
(Fig. 2A). With each head position,
the debris settles to the lowest portion of the canal, moving the debris
away from the ampulla, into the
common crus, and then into the utricle. With each change in position
(steps 2 4), the movement of debris
through the canal and away from the
ampulla may create changes in pressure across the cupula, resulting in
the generation of the typical torsional and upbeating nystagmus
predicting the successful outcome of
the maneuver (Fig. 3A; video, available at ptjournal.apta.org).17 If, during the second or third position of
the maneuver (or both), the move-

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<LEAP> Case #24 Applying Evidence to a Patient With BPPV

Figure 1.
Mechanisms of benign paroxysmal positional vertigo (BPPV), illustrated for left posterior semicircular canal BPPV. The crista ampullaris
of the fluid-filled semicircular canals contains sensory epithelium consisting of hair cells embedded within the cupula, a fine,
gelatinous membrane. Rotation of the head deflects the hair cells. The macula utriculi consists of a weighted sensory membrane
containing hair cells implanted within an otolithic membrane weighted with calcite particles (otoconia). Gravitational forces on the
head deflect the hair cells. Reprinted with permission from American Dizziness and Balance. Copyright 2007.

ment of debris through the canal

reverses direction, with the debris
moving toward the ampulla, a reversal in the direction of nystagmus may
be observedpredicting treatment
failure (Fig. 3B).17 Video oculograAvailable With
This Article at
ptjournal.apta.org
A video of the canalith
repositioning procedure for
benign paroxysmal vertigo in the
left posterior semicircular canal.

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Physical Therapy

phy should be used to monitor nystagmus in response to the movement

of debris through the canals and to
prevent the suppression of nystagmus. The procedure is repeated a
minimum of 3 times within a treatment session. Repeating the CRP
more than once is significantly more
effective than performing the CRP
only once within a treatment
session.18
Acceptable modifications of the CRP
(described by Epley) include performance of the CRP without mastoid
vibration (thought to prevent debris

from adhering to the canal walls) and

self-administration of the CRP.5,6 The
short-term outcome is the same for
patients with and patients without
postintervention postural and activity restrictions.19,20 However, fewer
treatment sessions are required to
produce a negative Dix-Hallpike test
result if postintervention postural
and activity restrictions are maintained.21 To determine the results of
the CRP, the Dix-Hallpike test should
be performed optimally more than
24 hours after treatment to avoid the
effects of fatigue.22 A successful outcome is defined as conversion from a

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<LEAP> Case #24 Applying Evidence to a Patient With BPPV

positive Dix-Hallpike test result to a
negative one (ie, no benign paroxysmal positional nystagmus and no
associated vertigo).
In a Cochrane systematic review,
Hilton and Pinder23 examined the
evidence to determine the effectiveness of the CRP relative to that of
other treatments or no treatment for
people with posterior canal BPPV.
That review was an update of a
Cochrane review first published in
The Cochrane Library in 2002 (issue
1) and then updated in 2004 and
2007. Randomized controlled trials
were included if participants were
adults (16 years old) and had a clinical diagnosis of posterior canal
BPPV based on a positive result on
the Dix-Hallpike test (observation of
the characteristic nystagmus and
symptoms of associated vertigo). Trials compared the effectiveness of the
modified CRP (without the use of
vibration) with that of a sham
maneuver or no treatment (control).
There was no evidence comparing
the effectiveness of the CRP with
that of other physical, medical, or
surgical therapies for posterior canal
BPPV. Follow-up ranged from less
than 24 hours22,24 to 1 to 2 weeks25
and 1 month26,27 after treatment. The
primary outcomes included complete resolution of symptoms and
conversion from a positive to a negative Dix-Hallpike test result, the
only objective physiological change
resulting from treatment. The search
date of the review was May 19, 2010.
A summary of the findings is given in
the Appendix.

Take-Home Message
The review reported the results of 5
randomized controlled trials involving 292 adults with a clinical diagnosis of posterior canal BPPV based on
history and a positive result on the
Dix-Hallpike test. The outcome of
the CRP was compared with that of
no treatment (control) in 1 study27
or a sham treatment in the remaining
October 2014

Figure 2.
Particle repositioning maneuvers. (A) Canalith repositioning procedure, illustrated for
treatment of the right posterior semicircular canal. The clinician moves the patient
through a series of 4 positions, starting with the placement of the involved canal in the
head-hanging position of the Dix-Hallpike test. To begin, the patient is positioned on
the treatment table in the sitting position with the legs extended. The patients head is
rotated 45 degrees toward the right. The patient is then lowered into the supine
position with the neck extended 30 degrees over the edge of the treatment table. This
is the head-hanging position. The head is rotated through 90 degrees of motion ending
in 45 degrees of neck rotation toward the uninvolved side. This step is followed by
rolling onto the uninvolved side while maintaining the position of the head in relation
to the trunk and, finally, sitting up from lying on the uninvolved side. Each position is
maintained for a minimum of 45 seconds or as long as the nystagmus lasts plus an
additional 20 seconds. The procedure is repeated 3 times. (B) Liberatory (Semont)
maneuver, illustrated for treatment of the right posterior semicircular canal. The patient
sits on the edge of the treatment table. The clinician rapidly moves the patient so that
he or she is lying on the involved side with the head rotated 45 degrees toward the
uninvolved side. While maintaining the position of the head in relation to the trunk, the
clinician swings the patient from lying on the involved side to lying on the uninvolved
side. The head is then gently tapped on the treatment table. Each position is maintained
for 1.5 minutes. The procedure is repeated 3 times. Reprinted with permission from
American Dizziness and Balance. Copyright 2007.

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<LEAP> Case #24 Applying Evidence to a Patient With BPPV

The magnitude of the effect of the
CRP compared with that of the sham
treatment or the control was significant in all 5 studies. The pooled odds
in favor of conversion from a positive to a negative Dix-Hallpike test
result were 6.40 times higher (95%
CI3.6311.28) with the CRP than
with the sham treatment or the control.22,24 27 The individual odds in
favor of symptom resolution varied
from 3.03 (95% CI1.019.07) to
37.33 (95% CI8.75159.22). There
were no reported adverse effects or
serious complications of treatment.
Reported complications included
the inability to tolerate positions
because of cervical spine dysfunction,25 emesis during treatment,22,25
nausea,22 and fainting.27
Figure 3.
Movement of debris within the right posterior semicircular canal during the canalith
repositioning procedure, illustrated for treatment of the right posterior semicircular
canal. The arrow indicates the direction of angular velocity and the flow of endolymph.
The cupula acts as a plunger (diaphragm within the ampulla). (A) Prediction of successful outcome. With each position of the head, debris settles away from the cupula,
creating an ampullofugal flow of endolymph away from the cupula, exciting the hair
cells within the crista ampullaris, and generating the same direction of nystagmus (Ny).
(B) Prediction of failed outcome. In the second or third position (or both), debris settles
toward the cupula, reversing the direction of flow of endolymph toward the ampulla
(ampullopetal), inhibiting the hair cells within the crista ampullaris, and reversing the
direction of nystagmus.

4 studies.22,24 26 The sham treatment

consisted of lying on the affected
side for 5 minutes,25 lying in the first
lateral position of the liberatory
maneuver,26 or CRP performed as if
the opposite ear were affected.22,24
In 2 trials, participants were given
instructions on postintervention
restrictions25,26; in 3 trials, no postintervention
restrictions
were
included.22,24,27 The overall risk for
bias was graded low for 4 trials22,24 26 but could not be determined for 1 trial.27
Pooled data showed a statistically significant difference in symptom resolution and in conversion from a positive to a negative Dix-Hallpike test
result in favor of the CRP.23 At short1376

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term follow-up (1 month), the

rates of subjective symptom resolution for patients treated with the
CRP were 32% to 80%,22,24 27 those
obtained with the sham treatment
were 10% to 34%,22,24 26 and that
obtained with the control was 35%.27
The pooled odds in favor of complete subjective symptom resolution
were 4.42 times higher (95%
CI2.627.44) with the CRP than
with the sham treatment or the control.22,24 27 At short-term follow-up,
the success rates for patients who
converted to a negative Dix-Hallpike
test result when treated with the
CRP were 34% to 89%,22,24 27 those
obtained with the sham treatment
were 10% to 38%,22,24 26 and that
obtained with the control was 65%.27

Case #24: CRP for

Treatment of Posterior
Semicircular Canal BPPV
Can CRP help this patient?
Dr X is a 40-year-old woman with a
7-year history of episodic positional
vertigo, the most recent episode
beginning 7 days earlier, when she
rolled over in bed and woke with
severe vertigo and nausea. She was
evaluated by a neuro-otologist, diagnosed with BPPV, and referred to
outpatient physical therapy for vestibular rehabilitation. To differentiate between BPPV and other causes
of dizziness, the physical therapist
evaluated self-report participation
questionnaires, a history, a neurologic screen, and positional testing.
The patient completed the Dizziness
Handicap Inventory,28 designed to
evaluate self-perceived handicap due
to dizziness, and the Activitiesspecific Balance Confidence Scale,29
designed to evaluate self-perceived
balance confidence in performing
household and community activities
(Table). The patient reported constant nausea; vertigo when rolling in
bed toward the right, getting in and
out of bed, bending forward, looking
up, and moving her head rapidly;
and vomiting during the physicians

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<LEAP> Case #24 Applying Evidence to a Patient With BPPV

Table.
Preintervention and Postintervention Outcome Measures
Outcome Measure

Range
(Points)

Properties of Measure

Preintervention

Postintervention

Activities-specific Balance
Confidence Scale29

0100

Higher score indicates greater balance confidence; has strong

test-retest reliability and high internal consistency in older
adults dwelling in the community29 and is valid in people
with complaints of dizziness38

80

100

Dizziness Handicap
Inventory28

0100

Higher score indicates greater self-perceived handicapping

effects imposed by vestibular system disease

84

Dynamic Gait Index30

024

Score of 19 points indicates increased risk of falling in older

adults dwelling in the community39 and patients with
vestibular disorders40; moderate interrater reliability in
patients with vestibular disorders41

15

24

Timed Up & Go Test31

For adults who are asymptomatic, healthy, and in the fourth

decade of life, the mean time to complete is 4.6 s (SD1.0,
range3.36.6)42

examination. She slept in bed

propped upright on 5 pillows to
avoid provoking positions, experienced difficulty concentrating at
work, and felt anxious. The patients
history and findings on the Dizziness
Handicap
Inventory
suggested
severe BPPV. Due to the severity of
the BPPV, to reduce the risk of emesis, and to prevent suppression of
ocular nystagmus, the patient medicated with ondansetron (Zofran,
GlaxoSmithKline, Research Triangle
Park, North Carolina) before the
evaluation, in accordance with her
physicians order.
The results of the neurologic screen
were negative. The patient had no
contraindications for further positional testing or a particle repositioning maneuver. Functional outcome
measures administered included the
Dynamic Gait Index,30 designed to
evaluate postural stability during various walking tasks, and the Timed
Up & Go Test,31 a measurement of
walking speed (Table). The DixHallpike test was performed with the
use of video oculography to avoid
the visual fixation that suppresses
ocular nystagmus and to digitally
record eye movements. In the DixHallpike test, the result for the left
head hanging position was negative.
The result for the right head hanging
position was positive; typical nystagOctober 2014

mus counterclockwise torsional

(superior pole of the eye directed
toward the lowermost ear) and
upbeatingwas observed, with a
2-second latency before the onset of
nystagmus, a duration of nystagmus
of 21 seconds, and a peak intensity
of velocity of nystagmus of 8 of 10
(0no nystagmus; 10extreme nystagmus). The patient complained of
severe vertigo associated with nystagmus and became nauseated. After
the patient was returned to the
upright position, strong downbeating nystagmus associated with vertigo and disorientation to vertical
was noted. The patients history and
findings on the Dix-Hallpike test suggested BPPV involving the right posterior canal. The patient was identified as a good candidate for the CRP
for right posterior canal BPPV. The
mechanism of BPPV and treatment
options were discussed with the
patient. She was informed of potential treatment complications, such as
canal conversion (movement of
debris into another canal), canal jam
(movement of debris from a wide to
a narrow portion of the canal, resulting in plugging of the canal), further
nausea, emesis, and further imbalance. She understood that the treatment risks were minimal and consented to CRP treatment for right
posterior canal BPPV.

9s

5s

The physical therapy intervention

consisted of performance of the CRP
on the right without the use of mastoid vibration. Each position was
maintained for the duration of nystagmus in the second step plus 20
seconds (Fig. 2A). Video oculography was used to observe nystagmus
in each position to monitor treatment progress. For optimal effectiveness of the maneuver, 3 cycles of the
CRP were performed in 1 treatment
session. During the first cycle, counterclockwise torsional and upbeating
nystagmus was observed in the second, third, and fourth steps, suggesting the movement of debris away
from the right posterior canal
ampulla and successful treatment.17
The nystagmus was associated with
vertigo. The patient felt nauseated
but did not have emesis. During the
second and third cycles of the CRP,
no nystagmus was observed, and the
patient did not complain of vertigo
or nausea. After the procedure, the
patient sat in the clinic for 20 minutes to allow debris to settle and to
be supported if she experienced sudden imbalance or vertigo. She was
instructed in postural and activity
restrictions to minimize the number
of treatment sessions. She was
instructed to sleep on the uninvolved side with her head elevated
on a wedge made of 3 pillows and to
avoid up and down movements of

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<LEAP> Case #24 Applying Evidence to a Patient With BPPV

the head for 1 week. She was given
information describing the mechanisms of BPPV, treatment options,
posttreatment postural and activity
restrictions, and the recurrence of
BPPV. She was instructed to have
someone drive her home.
The treatment results were evaluated
at a 1-week follow-up. Success was
defined as no subjective complaints
of vertigo and conversion from a positive to a negative Dix-Hallpike test
result. The patient reported maintaining postural and activity restrictions and experiencing no episodes
of positional vertigo or symptoms of
nausea during her daily routine. The
total score on the Dizziness Handicap Inventory suggested no selfperceived handicap due to dizziness,
and the total scores on the Activitiesspecific Balance Confidence Scale
and the Dynamic Gait Index suggested no residual balance deficits
(Table). The patients gait speed on
the Timed Up & Go Test was
within normal limits for her age
(Table). The Dix-Hallpike test was
performed with video oculography.
No nystagmus was observed, and the
patient did not complain of vertigo.
The findings suggested the successful resolution of BPPV after treatment with the CRP. The patient was
educated in the probability of the
recurrence of BPPV and factors associated with recurrence. Further
intervention was not indicated.
How did the results of the
Cochrane review apply to Dr X?
The physical therapist considered
whether Dr X would be a good candidate for the use of the CRP to treat
right posterior canal BPPV. Using the
PICO (Patient, Intervention, Comparison, Outcome) format, the clinician asked the following question:
Will a 40-year-old woman diagnosed
with right posterior semicircular
canal BPPV benefit from the CRP to
resolve symptoms of vertigo and to
convert from a positive to a negative
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Dix-Hallpike test result? On the

basis of history and findings on the
Dix-Hallpike test, Dr X had a diagnosis of right posterior canal BPPV. The
results of the Cochrane review may
be applied directly to Dr X. The participants were similar in age and sex
and had similar symptoms of positional vertigo.
Our procedure matched the published protocols of articles described
in the Cochrane review. The CRP
consisted of a series of 4 positions
without the use of mastoid vibration.22,24 27 The duration of each
position was the duration of nystagmus plus 20 seconds.25,26 Three
cycles of the CRP were performed,
and no nystagmus was observed during the second and third cycles. The
CRP was repeated until no nystagmus was observed; alternatively, a
maximum of 5 cycles can be performed to optimize success.22,25,26
After the maneuver, the patient was
instructed in postural and activity
restrictions, with the exception of
wearing a soft cervical collar,25,26 to
reduce the number of treatment sessions required to produce a negative
Dix-Hallpike test result.
How well do the outcomes of the
intervention provided to Dr X
match those suggested by the
systematic review?
In 1 treatment session, Dr X
achieved her goal of the resolution
of all symptoms of vertigo during her
daily routine. The therapist achieved
her goal of conversion from a positive to a negative Dix-Hallpike test
result with no subjective complaints
of vertigo. The successful resolution
of posterior canal BPPV with 1 CRP
treatment session is consistent with
the reported Cochrane review findings.23 After 1 treatment session, the
average short-term rates of success
of the CRP for the complete resolution of symptoms ranged from 34%
to 89%,22,24 27 with an average rate
of 57% (SD18%). For conversion

from a positive to a negative DixHallpike test result, the average

short-term rates of success of the
CRP ranged from 34% to 89%,22,24 27
with an average rate of 72%
(SD23%).23
Dr Xs perceived level of handicap
due to dizziness and perceived level
of balance confidence in performing
household and community activities
returned to normal. Balance control
during gait activities and speed of
gait returned to age-appropriate levels. Participation and functional level
goals were not included in the trials
and therefore were not included in
the Cochrane review. Dr Xs positive
outcomes exceeded those that were
significant in the Cochrane review.
Can you apply the results of the
systematic review to your own
patients?
All 292 participants in the trials
included in the Cochrane review
were diagnosed with posterior canal
BPPV on the basis of history and findings on the Dix-Hallpike test. After 1
treatment session, the average shortterm rate of success of the CRP for
complete symptom resolution was
57% (SD18%), and that for conversion from a positive to a negative
Dix-Hallpike test result was 72%
(SD23%).23 There were few
reported adverse effects of treatment
and no serious complications. The
only reported limitations were emesis and cervical dysfunction preventing positioning of the head. The
results of the Cochrane review23 may
be applied to patients diagnosed
with posterior canal BPPV. However, long-term follow-up was lacking in all of the trials. Therefore,
there is no good evidence that the
CRP provides a long-term resolution
of symptoms. At the time of the
search date, there was no good evidence comparing the CRP with
other particle repositioning maneuvers, medical intervention, or surgi-

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<LEAP> Case #24 Applying Evidence to a Patient With BPPV

cal intervention for posterior canal
BPPV.
Two double-blind randomized shamcontrolled trials assessed the shortterm efficacy of the liberatory
maneuver, an alternative particle
repositioning maneuver, for the
treatment of posterior canal BPPV32
(Fig. 2B). At short-term follow-up,
the rates of subjective symptom resolution for patients treated with the
liberatory maneuver were 85%33 and
87%,34 and those obtained with the
sham treatment were 0%34 and
14%.33 The presence of nystagmus in
the same direction in the second and
third steps suggested successful
treatment.35 Side effects included
transient nausea, vomiting, pallor,
sweating, and loss of balance.33,34 No
trials have been done to directly
compare the liberatory maneuver
with the CRP.
Other treatments for posterior semicircular canal BPPV include BrandtDaroff exercises (habituation exercises).36,37 Subsequent to the
Cochrane review search date, 2 trials
were done to compare the CRP with
Brandt-Daroff exercises, the liberatory maneuver, and no treatment
(control). At 1 week, the short-term
success rates were 81%36 and 87%37
for the CRP, 25%36 and 35%37 for the
Brandt-Daroff exercises, 53% for the
liberatory maneuver,37 and 15% for
the control.37 Brandt-Daroff exercises were as effective as the control
at 1 week.37
What can be advised based on
the results of this systematic
review?
The available data are sufficient to
determine that the CRP is a safe and
effective short-term treatment for
posterior canal BPPV. After 1 treatment session, the CRP successfully
resolves symptoms of vertigo and
converts a positive Dix-Hallpike test
result to a negative one. At shortterm follow-up, individual trials and
October 2014

pooled data show a statistically significant effect in favor of the CRP

over the control. The CRP is safe,
with no serious complications.
There is no good evidence that the
CRP provides a long-term resolution
of symptoms. At the time of the
search, there was no good evidence
comparing the CRP with other physical, medical, or surgical therapies
for posterior canal BPPV. Future
updates of the review need to take
into account subsequent studies
comparing the CRP with other physical therapy treatments for posterior
canal BPPV, examining the effect
size stratified by symptom duration,
and comparing long-term follow-up
of symptom resolution with the CRP
and long-term follow-up of symptom
resolution with other physical therapy treatments.
J.O. Helminski, PT, PhD, Physical Therapy,
Midwestern University, 555 31st St, Downers Grove, IL 60515 (USA). Address all correspondence
to
Dr
Helminski
at:
jhelmi@midwestern.edu.
[Helminski JO. Effectiveness of the canalith
repositioning procedure in the treatment of
benign paroxysmal positional vertigo. Phys
Ther. 2014;94:13731382.]
2014 American Physical Therapy Association
Published Ahead of Print: June 5, 2014
Accepted: May 26, 2014
Submitted: June 7, 2013
Special thanks are due to Janet Callahan, PT,
DPT, MS, NCS, Sarah Hourihan, PT, DPT,
Rene Crumley, PT, DPT, NCS, CEEAA, and
Tammie Ostrowski, PT, for assisting with the
acquisition of digital recordings of nystagmus. Special thanks also are due to Eric
Sanderson, PT, DPT, for illustrating Figure 3
(prediction of canalith repositioning procedure success and failure).
DOI: 10.2522/ptj.20130239

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Appendix.
Cochrane Review Results23 for Effectiveness of the Canalith Repositioning Maneuver (CRP) in the Treatment of Posterior
Semicircular Canal Benign Paroxysmal Positional Vertigo (BPPV)

Study Characteristics
Five small-scale randomized controlled trials were included (search date: May 19, 2010).
Participants were 292 adults (16 years old) with a clinical diagnosis of posterior canal BPPV based on history
and a positive result on the Dix-Hallpike test. All studies included participants with unilateral posterior canal
BPPV. One study also included participants with bilateral posterior canal BPPV and atypical BPPV. The duration
of participants symptoms varied.
Intervention was modified CRP (no mastoid vibration). The CRP was compared with a sham maneuver in 4 trials
and a control in 1 trial.
Follow-up ranged from immediately to 1 month after treatment.
Interventions
Type of particle repositioning maneuver: CRP, sham maneuver (lying on the affected side for 5 minutes, lying
in the first lateral position of the liberatory maneuver for 5 minutes, and CRP performed as if the opposite ear
were affected), and control (untreated).
Number of cycles per treatment session: 1 to 5.
Postintervention postural and activity restrictions: in 2 trials, participants were given instructions on postintervention restrictions; in 3 trials, no postintervention restrictions were included.
Outcomes
Proportion of participants who had complete resolution of their symptoms and who converted from a positive
to a negative result on the Dix-Hallpike test.
In 2 studies, participants were asked to complete a diary of symptoms.

Froehling et al25
Measure

Munoz et al24

von Brevern
et al22

Yimtae et al27

CRP

Sham

CRP

Sham

CRP

Sham

CRP

Sham

CRP

Control

No. of participants/group

24

26

18

15

38

41

35

31

29

27

No. (%) of participants/

group with complete
resolution of symptoms

12 (50)

5 (19)

11 (61)

3 (20)

12 (32)

10 (24)

28 (80)

4 (13)

12 (41)

1 (4)

No. (%) of participants/

group with negative
Dix-Hallpike test result

16 (67)

10 (38)

16 (89)

4 (27)

13 (34)

6 (15)

28 (80)

3 (10)

22 (76)

13 (48)

No. of participants/group
with complications
(nausea, vomiting,
fainting)

Overall assessment of risk

of bias
a

Lynn et al26

Low

Low

Low

Low

Insufficient data to
determine bias

Complete data were available for 273 of 292 participants.

(Continued)

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Appendix.
Continued

Results
Complete resolution of symptoms
Symptom outcome was reported as a dichotomous variable.
Success was defined as a complete resolution of symptoms or not.
In each trial, a statistically significant difference in symptom resolution in favor of the treatment group was
observed.
Pooled trial data yielded an odds ratio of 4.42 (95% confidence interval2.627.44) in favor of treatment.
Negative Dix-Hallpike test result
In all trials, there was a statistically significant difference in conversion from a positive to a negative Dix-Hallpike
test result in favor of the treatment group.
Pooled trial data yielded an odds ratio of 6.40 (95% confidence interval3.6311.28) in favor of treatment.
Safety
No serious complications of treatment were reported.
Reported problems were inability to tolerate treatment because of cervical spine problems, emesis during
treatment, nausea, and fainting.
Limitations
None of the trials assessed outcomes after 1 month, so long-term efficacy is unknown.
At the time of the search, there were no trials comparing CRP with other active treatments.

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