What is the proper technique for performing the Epley maneuver for Benign Paroxysmal Positional Vertigo (BPPV)?

How to Perform the Epley Maneuver for BPPV

The Epley maneuver is the most effective treatment for posterior canal BPPV, with patients 6.5 times more likely to experience symptom improvement compared to controls and should be performed following a specific 5-step sequence to properly reposition the displaced otoconia. 1

Step-by-Step Technique for the Epley Maneuver

1. Starting Position:

   • Place the patient in an upright sitting position
   • Turn the patient's head 45° toward the affected ear (the ear that was positive on Dix-Hallpike testing)

2. First Position Change:

   • Rapidly lay the patient back to a supine position with the head hanging 20° below horizontal
   • Maintain this position for 20-30 seconds (or until nystagmus subsides)

3. Second Position Change:

   • Turn the patient's head 90° toward the unaffected side
   • Hold this position for about 20 seconds

4. Third Position Change:

   • Rotate the patient's head an additional 90° in the same direction (requiring the patient to roll from supine to lateral decubitus position)
   • The patient's head should now be nearly face-down
   • Hold this position for 20-30 seconds

5. Final Position:

   • Return the patient to an upright sitting position
   • This completes the maneuver

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Clinical Efficacy and Outcomes

The Epley maneuver has strong evidence supporting its effectiveness:

• Complete resolution of vertigo occurs significantly more often with the Epley maneuver compared to sham treatments or controls (OR 4.42) 1
• Patients treated with the Epley maneuver have 6.5 times greater chance of symptom improvement compared to controls 1
• Conversion from positive to negative Dix-Hallpike test is more likely with the Epley maneuver (OR 9.62) 1
• The number-needed-to-treat is approximately 3 patients to achieve symptom resolution 2

Important Clinical Considerations

• Success Rate: 37.7% of patients may become asymptomatic after just one session, while 61.5% may require repeated sessions 3
• Monitoring: Reassess patients within 1 month after treatment to confirm symptom resolution 4
• Superiority to Other Treatments: A single Epley maneuver is >10 times more effective than a week of Brandt-Daroff exercises 1, 4
• No Post-Procedure Restrictions: Postprocedural restrictions are not recommended after the Epley maneuver 4

Potential Challenges and Pitfalls

• Patient Limitations: Patients with cervical stenosis or severe rheumatoid arthritis may require modified techniques 4
• Risk Factors for Treatment Failure: Previous ipsilateral BPPV and high-intensity nystagmus may predict lower success rates 5
• Recurrence: BPPV has a recurrence rate of approximately 36%, making patient education about potential recurrence crucial 4
• Canal Switching: Partial response may sometimes be due to canal switching during BPPV treatment 3

When to Consider Additional Testing

Comprehensive vestibular function testing is warranted in patients:

1. Exhibiting atypical nystagmus
2. Suspected of having additional vestibular pathology
3. With failed (or repeatedly failed) response to the Epley maneuver
4. With frequent recurrences of BPPV 1

The Epley maneuver is a simple, cost-effective procedure that can be performed in various healthcare settings without specialized equipment, making it accessible for most clinicians to learn and implement in their practice.