What is a Particle Repositioning Maneuver?
A particle repositioning maneuver (PRM), also called a canalith repositioning procedure (CRP), is a series of specific head and body movements designed to relocate displaced calcium carbonate crystals (otoconia) from the semicircular canals of the inner ear back into the vestibule, where they no longer cause vertigo symptoms. 1
How PRMs Work
The underlying mechanism involves guiding free-floating debris through the affected semicircular canal using gravity-assisted head positioning. 2 The crystals become dislodged from their normal location in the utricle and migrate into one of the three semicircular canals—most commonly (85-95% of cases) the posterior canal. 2 By systematically moving the patient's head through specific angles and positions, the maneuver uses gravity to move these particles back to their original location where they can be reabsorbed. 1
Types of Repositioning Maneuvers by Canal Involvement
Posterior Canal BPPV (85-95% of cases)
Epley Maneuver: The first-line treatment with 80% success rates after 1-3 treatments and 90-98% success with repeat maneuvers if needed. 2 The procedure involves: starting with the patient sitting upright with head turned 45° toward the affected ear, rapidly laying back to a supine head-hanging 20° position for 20-30 seconds, turning the head 90° toward the unaffected side and holding for 20-30 seconds, rolling the patient onto their side while maintaining head position, and finally returning to upright position. 2, 3
Semont (Liberatory) Maneuver: An alternative with comparable efficacy showing 94.2% resolution at 6-month follow-up. 2 This involves rapid movements from sitting to side-lying on the affected side, then quickly to the opposite side without changing head position relative to the shoulder. 2
Horizontal (Lateral) Canal BPPV (10-15% of cases)
Barbecue Roll (Lempert) Maneuver: First-line treatment with 50-100% success rates, involving rolling the patient 360 degrees in sequential 90-degree steps. 2, 4
Gufoni Maneuver: Achieves 93% success rates and is easier to perform than the Barbecue Roll. 2, 4 For the geotropic variant, the patient moves from sitting to side-lying on the unaffected side, then turns the head 45-60° toward the ground. 2
Anterior Canal BPPV (rare, <5% of cases)
- Deep head hanging maneuvers are used, though evidence is weaker due to the rarity of this variant. 4
Clinical Efficacy and Evidence
The evidence supporting PRMs is robust. Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20). 2 A single Epley maneuver is more than 10 times more effective than a week of Brandt-Daroff exercises performed three times daily (OR 12.38; 95% CI 4.32-35.47). 2, 3 Complete resolution of vertigo increases from 21% to 56% with the Epley maneuver compared to sham treatment. 3
Important Clinical Considerations
Post-procedural restrictions are NOT recommended—patients can resume normal activities immediately after treatment. 1, 2 This represents a significant change from older practices that imposed unnecessary activity limitations. 1
Patients may experience transient symptoms during the maneuver including intense vertigo, nausea (occurring in 12-32% of patients), and a sensation of falling. 2, 3 These symptoms typically subside within 60 seconds. 2 Some patients report mild residual dizziness or motion sensitivity for a few days to weeks after successful treatment. 1, 2
Self-Treatment Options
Self-administered CRP can be taught to motivated patients after at least one properly performed in-office treatment, achieving 64% improvement compared to only 23% with self-administered Brandt-Daroff exercises. 2, 5 Each home maneuver cycle involves holding each position for 20-30 seconds through five sequential steps. 5
Common Pitfalls and Treatment Failures
Canal conversion (changing from one type of BPPV to another) occurs in approximately 6-7% of cases during treatment. 2 If symptoms persist after 2-3 properly performed maneuvers, reassess for persistent BPPV by repeating the diagnostic test, evaluate for multiple canal involvement, consider coexisting vestibular pathology, and rule out CNS disorders if atypical features are present. 2 Repeat CRPs achieve 90-98% success rates in treatment failures. 2
Special Populations
Elderly patients may require modified approaches due to cervical spine limitations, severe rheumatoid arthritis, or other musculoskeletal restrictions. 2, 4 In these cases, Brandt-Daroff exercises or referral to specialized vestibular physical therapy may be more appropriate. 2 The effectiveness of repositioning maneuvers is lower in patients over 70 years old, and recurrences are more frequent in this population. 6
Why PRMs Are Preferred Over Medications
The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. 1, 2 There is no evidence that these medications are effective as definitive treatment for BPPV, and they cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk—particularly dangerous in elderly patients. 2, 7 Medications may only be considered for short-term management of severe nausea or vomiting in severely symptomatic patients. 2