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Often the cause of vertigo is the displacement of small calcium carbonate crystals , or canaliths, within the inner ear. Canalith repositioning procedure (CRP) is a. The Epley maneuver, or canalith repositioning procedure (CRP), was invented by John Epley. The Epley maneuver with various modifications. This page includes the following topics and synonyms: Canalith Repositioning Procedure, Epley Maneuver.

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The Rfpositioning 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 interventions—medications, surgery, education, nutrition, exercise—and the evidence for and against the use of diagnostic tests for specific conditions.

The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo.

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. This article focuses on an adult patient with benign paroxysmal positional vertigo. Can a canalith repositioning procedure help this patient?

Benign paroxysmal positional vertigo BPPV presents as brief periods of vertigo experienced with a change in the position of a person’s 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.

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. 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.

Canalith Repositioning Procedure (CRP)

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 canaligh the hair cells.

Reprinted with permission from American Dizziness and Danalith. The diagnosis of BPPV is based on history and findings on positional testing. A comparison of the Dix-Hallpike test and the side-lying test revealed no significant difference between the 2 techniques. The diagnostic csnalith for posterior canal BPPV are vertigo associated with the characteristic nystagmus—torsional 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 onset 11 — 13 and a duration of less than 60 seconds 14 —and fatigue with repeated positioning.

Once cannalith, posterior canal BPPV may be effectively treated with a particle repositioning maneuver, such as the canalith repositioning maneuver CRP described by Epley. 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—4the 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.

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. 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 patient’s 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. 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 bothdebris settles toward the cupula, reversing the direction of flow of endolymph toward the ampulla ampullopetalinhibiting the hair cells within the crista ampullaris, and reversing the direction of nystagmus. 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.

Canalith Repositioning Procedure

In a Cochrane systematic review, Hilton and Pinder 23 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 Canslith in issue 1 and then updated in and 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 hours 2224 to 1 to 2 weeks 25 and 1 month 2627 after treatment.

The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo.

The primary outcomes included complete resolution of symptoms and conversion from a positive to a negative Canaalith test result, the only objective physiological change resulting from treatment. The search date of the review was May 19, The review reported the results of 5 randomized controlled trials involving 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 study 27 or a sham treatment in the remaining 4 studies. 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.

The pooled odds in favor of conversion from a positive to a negative Dix-Hallpike test result were 6. 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, 2225 nausea, 22 and fainting. 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 cxnalith 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 Activities-specific 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 tepositioning the physician’s examination.


She slept in bed propped upright on 5 pillows to avoid provoking positions, experienced difficulty concentrating at work, and felt anxious. 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 physician’s order.

The results of the neurologic screen were negative. The patient had no contraindications for further positional testing or a particle repositioning maneuver. The Dix-Hallpike 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 Dix-Hallpike test, the result for the left head hanging position was negative. The patient complained of severe vertigo associated with nystagmus and became nauseated. After the patient was returned to reposltioning upright position, strong downbeating nystagmus associated with vertigo and disorientation to vertical was eepositioning.

The mechanism of BPPV and treatment options were discussed with the patient. She was informed of potential treatment complications, such as canal conversion movement reposifioning debris into another canalcanal jam movement of debris from a wide to a narrow portion of the canal, resulting in plugging of the canalfurther nausea, emesis, and further imbalance. 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.

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 repositiohing 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. 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 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 self-perceived handicap due to canalithh, and the total scores on the Activities-specific Balance Confidence Scale and the Dynamic Gait Index suggested no residual balance deficits Table. The Dix-Hallpike test was performed with video oculography. No nystagmus was repositioniing, and the patient did not complain of vertigo.

The patient was educated in the probability of the recurrence of BPPV and factors associated with recurrence. Further intervention was not indicated.

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 repositiooning articles described in the Cochrane review. The CRP consisted of a series of 4 positions without the use of mastoid vibration.

The CRP was repeated until no nystagmus was xanalith alternatively, a maximum of 5 cycles can be performed to optimize success.