Epley maneuver

Last updated

Epley maneuver Epley maneuver.jpg
Epley maneuver

The Epley maneuver or repositioning maneuver is a maneuver used by medical professionals to treat one common cause of vertigo, benign paroxysmal positional vertigo (BPPV) [1] [ needs update ] of the posterior or anterior canals of the ear. [2] The maneuver works by allowing free-floating particles, displaced otoconia, from the affected semicircular canal to be relocated by using gravity, back into the utricle, where they can no longer stimulate the cupula, therefore relieving the patient of bothersome vertigo. [2] [3] The maneuver was developed by the physician John M. Epley, and was first described in 1980. [4]

Contents

A version of the maneuver called the "modified" Epley does not include vibrations of the mastoid process originally indicated by Epley, as the vibration procedures have been proven ineffective. [5] The modified procedure is now the one generally accepted as the Epley maneuver.

Effectiveness

An Epley maneuver is a safe and effective treatment for BPPV, although the condition recurs in approximately one third of cases. [6]

Sequence of positions

The following sequence of positions describes the Epley maneuver:

  1. The patient begins in an upright sitting posture, with the legs fully extended and the head rotated 45 degrees toward the side in the same direction that gives a positive Dix–Hallpike test.
  2. Then the patient is quickly lowered into a supine position (on the back), with the head held approximately in a 30-degree neck extension (Dix-Hallpike position), with the head remaining rotated to the side.
  3. The clinician observes the patient's eyes for "primary stage" nystagmus.
  4. The patient remains in this position for approximately 1–2 minutes.
  5. Then the patient's head is rotated 90 degrees in the opposite direction, so that the opposite ear faces the floor, while maintaining 30 degrees of neck extension.
  6. The patient remains in this position for approximately 1–2 minutes.
  7. Keeping the head and neck in a fixed position relative to the body, the patient rolls onto the shoulder, rotating the head another 90 degrees in the direction being faced. Now the patient is looking downward at a 45-degree angle.
  8. The eyes should be observed immediately by the clinician for "secondary stage" nystagmus (this secondary stage nystagmus should be in the same direction as the primary stage nystagmus).
  9. The patient remains in this position for approximately 1–2 minutes.
  10. Finally, the patient is slowly brought up to an upright sitting posture, while maintaining the 45-degree rotation of the head.
  11. The patient holds a sitting position for up to 30 seconds.

These steps may be repeated twice, for a total of three times during a procedure. During every step of this procedure, the patient may experience some dizziness.

Post-treatment phase

Following the treatment, the clinician may provide the patient with a soft collar, often worn for the remainder of the day, as a cue to avoid any head positions that may once again displace the otoconia. The patient may be instructed to be cautious of bending over, lying backward, moving the head up and down, or tilting the head to either side. For the next two nights, patients should sleep in a semi-recumbent position. This means sleeping with the head halfway between being flat and being upright (at a 45-degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch. The soft collar is removed occasionally. When doing so, the patient should be encouraged to perform horizontal movements of the head to maintain normal neck range of motion. [7] It is important to instruct the patient that horizontal movement of the head should be performed to prevent stiff neck muscles.

It remains uncertain whether activity restrictions following the treatment improve the effectiveness of the canalith repositioning maneuver. However, study patients who were not provided with any activity restrictions, needed one or two additional treatment sessions to attain a successful outcome. [8] The Epley maneuver appears to be a long-term, effective, and conservative treatment for BPPV that has a limited number of complications (nausea, vomiting, and residual vertigo) [2] and is well tolerated by patients. [9]

Background information

The goal of an Epley maneuver is to restore the equilibrium of the vestibular system, more specifically, to the semicircular canals, in order to treat the symptoms associated with BPPV. There is compelling evidence that free-floating otoconia, probably displaced from the otolithic membrane in the utricle are the main cause of this disequilibrium. [5] Recent pathological findings also suggest that the displaced otoconia typically settle in the posterior semicircular canal in the cupula of the ampulla and render it sensitive to gravity. [5] The cupula move in relation to acceleration of the head during rotary movements and signal to the brain via action potentials about which way the head is moving in relation to its surroundings. However, once a crystal becomes lodged in the cupula, it only takes slight head movements in combination with gravity, to create an action potential, which signals to the brain that the head is moving through space, when in reality, it is not, thus creating the experience of vertigo associated with BPPV. [10]

When a therapist is performing an Epley maneuver, the patient's head is rotated to 45 degrees in the direction of the affected side, in order to target the posterior semicircular canal of the affected side. [5] When the patient is passively positioned from an upright seated posture down to a supine (lying on the back) position, this momentum helps to dislodge the otoconia (crystal) embedded in the cupula. Steps 3–10 in the above-mentioned procedure are intended to cause the newly dislodged crystal to be brought back to the utricle through the posterior semicircular canal so that it can be re-absorbed by the utricle. [5]

In 1957, John M. Epley received his M.D. degree from the University of Oregon Medical School (now Oregon Health Sciences University). While a resident at Stanford Medical School he conducted original research on the first multichannel cochlear implant. He developed his BPPV technique in 1979. He died July 31, 2019. [11]

See also

Related Research Articles

<span class="mw-page-title-main">Sense of balance</span> Physiological sense regarding posture

The sense of balance or equilibrioception is the perception of balance and spatial orientation. It helps prevent humans and nonhuman animals from falling over when standing or moving. Equilibrioception is the result of a number of sensory systems working together; the eyes, the inner ears, and the body's sense of where it is in space (proprioception) ideally need to be intact.

A balance disorder is a disturbance that causes an individual to feel unsteady, for example when standing or walking. It may be accompanied by feelings of giddiness, or wooziness, or having a sensation of movement, spinning, or floating. Balance is the result of several body systems working together: the visual system (eyes), vestibular system (ears) and proprioception. Degeneration or loss of function in any of these systems can lead to balance deficits.

<span class="mw-page-title-main">Semicircular canals</span> Organ located in innermost part of ear

The semicircular canals are three semicircular interconnected tubes located in the innermost part of each ear, the inner ear. The three canals are the lateral, anterior and posterior semicircular canals. They are the part of the bony labyrinth, a periosteum-lined cavity on the petrous part of the temporal bone filled with perilymph. 

<span class="mw-page-title-main">Vestibulo–ocular reflex</span> Reflex where rotation of the head causes eye movement to stabilize vision

The vestibulo-ocular reflex (VOR) is a reflex that acts to stabilize gaze during head movement, with eye movement due to activation of the vestibular system, it is also known as the Cervico-ocular reflex. The reflex acts to stabilize images on the retinas of the eye during head movement. Gaze is held steadily on a location by producing eye movements in the direction opposite that of head movement. For example, when the head moves to the right, the eyes move to the left, meaning the image a person sees stays the same even though the head has turned. Since slight head movement is present all the time, VOR is necessary for stabilizing vision: people with an impaired reflex find it difficult to read using print, because the eyes do not stabilise during small head tremors, and also because damage to reflex can cause nystagmus.

<span class="mw-page-title-main">Vestibular system</span> Sensory system that facilitates body balance

The vestibular system, in vertebrates, is a sensory system that creates the sense of balance and spatial orientation for the purpose of coordinating movement with balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of the inner ear in most mammals.

<span class="mw-page-title-main">Benign paroxysmal positional vertigo</span> Medical condition

Benign paroxysmal positional vertigo (BPPV) is a disorder arising from a problem in the inner ear. Symptoms are repeated, brief periods of vertigo with movement, characterized by a spinning sensation upon changes in the position of the head. This can occur with turning in bed or changing position. Each episode of vertigo typically lasts less than one minute. Nausea is commonly associated. BPPV is one of the most common causes of vertigo.

<span class="mw-page-title-main">Electronystagmography</span> Medical intervention

Electronystagmography (ENG) is a diagnostic test to record involuntary movements of the eye caused by a condition known as nystagmus. It can also be used to diagnose the cause of vertigo, dizziness or balance dysfunction by testing the vestibular system. Electronystagmography is used to assess voluntary and involuntary eye movements. It evaluates the cochlear nerve and the oculomotor nerve. The ENG can be used to determine the origin of various eye and ear disorders.

<span class="mw-page-title-main">Vertigo</span> Type of dizziness where a person has the sensation of moving or surrounding objects moving

Vertigo is a condition in which a person has the sensation that they are moving, or that objects around them are moving, when they are not. Often it feels like a spinning or swaying movement. It may be associated with nausea, vomiting, perspiration, or difficulties walking. It is typically worse when the head is moved. Vertigo is the most common type of dizziness.

<span class="mw-page-title-main">Vestibular nerve</span> Branch of the vestibulocochlear nerve

The vestibular nerve is one of the two branches of the vestibulocochlear nerve. In humans the vestibular nerve transmits sensory information from vestibular hair cells located in the two otolith organs and the three semicircular canals via the vestibular ganglion of Scarpa. Information from the otolith organs reflects gravity and linear accelerations of the head. Information from the semicircular canals reflects rotational movement of the head. Both are necessary for the sensation of body position and gaze stability in relation to a moving environment.

<span class="mw-page-title-main">Ampullary cupula</span>

The ampullary cupula, or cupula, is a structure in the vestibular system, providing the sense of spatial orientation.

<span class="mw-page-title-main">Otolithic membrane</span>

The otolithic membrane is a fibrous structure located in the vestibular system of the inner ear. It plays a critical role in the brain's interpretation of equilibrium. The membrane serves to determine if the body or the head is tilted, in addition to the linear acceleration of the body. The linear acceleration could be in the horizontal direction as in a moving car or vertical acceleration such as that felt when an elevator moves up or down.

The Dix–Hallpike or Nylén–Bárány test is a diagnostic maneuver from the group of rotation tests used to identify benign paroxysmal positional vertigo (BPPV).

<span class="mw-page-title-main">DizzyFIX</span>

The DizzyFIX is a home medical device designed to assist in the treatment of benign paroxysmal positional vertigo (BPPV) and its associated vertigo. The device is a head-worn representation of semi-circular canals. The device is filled with fluid and a particle representing the otoconia associated with BPPV. The device works like a visual set of instructions and guides the user through the treatment maneuver for BPPV. This maneuver is called the particle repositioning maneuver or Epley maneuver.

<span class="mw-page-title-main">Nystagmus</span> Dysfunction of eye movement

Nystagmus is a condition of involuntary eye movement. People can be born with it but more commonly acquire it in infancy or later in life. In many cases it may result in reduced or limited vision.

Videonystagmography (VNG) is a type of testing used to assess vestibular and central nervous system function through the use of eye movement tracking, specifically evaluating nystagmus. The older version of technology used to performed these tests, known as electronystagmography (ENG), leverages electrophysiological signals. There is a battery of tests which can be performed using this technology and testing, typically performed by an audiologist. These tests can be diagnostic in nature or used to monitor rehabilitation. The testing typically takes place in a dark or dimmed room with the patient laying or sitting, depending on the test, on a table or chair that can lean back to a flat position. The patient wears goggles containing a camera that tracks the pupils using infrared imaging; the video eye-tracking system records and sends pupil movement tracings to a computer typically with VNG analysis software. The goggles may also have a cover in order to deny vision for some tests while still recording eye movement. There may be some kind of screen or light bar used to present visual stimuli, though providers may use other kinds of visual stimuli for portions of the testing. VNG can determine whether dizziness is caused by inner ear disease, particularly benign paroxysmal positional vertigo (BPPV), as opposed to some other cause such as low blood pressure or anxiety.

The righting reflex, also known as the labyrinthine righting reflex, or the Cervico-collic reflex; is a reflex that corrects the orientation of the body when it is taken out of its normal upright position. It is initiated by the vestibular system, which detects that the body is not erect and causes the head to move back into position as the rest of the body follows. The perception of head movement involves the body sensing linear acceleration or the force of gravity through the otoliths, and angular acceleration through the semicircular canals. The reflex uses a combination of visual system inputs, vestibular inputs, and somatosensory inputs to make postural adjustments when the body becomes displaced from its normal vertical position. These inputs are used to create what is called an efference copy. This means that the brain makes comparisons in the cerebellum between expected posture and perceived posture, and corrects for the difference. The reflex takes 6 or 7 weeks to perfect, but can be affected by various types of balance disorders.

Benign paroxysmal vertigo of childhood is a neurological disorder that causes vertigo, a type of dizziness, in children. It is one of the most common causes of vertigo in children and is considered a subtype of migraine. BPVC is characterized by repeated, sudden episodes of vertigo that stop without intervention, typically lasting a few minutes. It is thought to occur due to a decrease in blood flow to the vestibular system, which regulates the body's balance and sense of position in space. These episodes do not require treatment and typically resolve by adolescence.

<span class="mw-page-title-main">Vestibular rehabilitation</span> Form of physical therapy for vestibular disorders

Vestibular rehabilitation (VR), also known as vestibular rehabilitation therapy (VRT), is a specialized form of physical therapy used to treat vestibular disorders or symptoms, characterized by dizziness, vertigo, imbalance, posture, and vision. These primary symptoms can result in secondary symptoms such as nausea, fatigue, and difficulty concentrating. Symptoms of vestibular dysfunction can significantly decrease quality of life, introducing mental-emotional issues such as anxiety and depression, and greatly impair an individual, causing them to become more sedentary. Decreased mobility can result in weaker muscles, less flexible joints, and worsened stamina, as well as decreased social and occupational activity. Vestibular rehabilitation therapy can be used in conjunction with cognitive behavioral therapy in order to reduce anxiety and depression resulting from a change in lifestyle.

Epley may refer to:

<span class="mw-page-title-main">Anita Bhandari</span> Indian surgeon

Anita Bhandari is an Indian neurotologist, otorhinolaryngologist, entrepreneur and author based in Jaipur. She is the co-founder and director of NeuroEquilibrium, which has set up over 175 dizziness and balance disorder clinics in India and abroad.

References

  1. ↑ Hilton, Malcolm P; Pinder, Darren K (2004). Hilton, Malcolm P (ed.). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". Cochrane Database of Systematic Reviews (2): CD003162. doi:10.1002/14651858.CD003162.pub2. PMID   15106194.
  2. 1 2 3 Prokopakis, Emmanuel P.; Chimona, Theognosia; Tsagournisakis, Minas; Christodoulou, Panagiotis; Hirsch, Barry E.; Lachanas, Vassilios A.; Helidonis, Emmanuel S.; Plaitakis, Andreas; Velegrakis, George A. (2005). "Benign Paroxysmal Positional Vertigo: 10-Year Experience in Treating 592 Patients with Canalith Repositioning Procedure". The Laryngoscope. 115 (9): 1667–71. doi:10.1097/01.mlg.0000175062.36144.b9. PMID   16148714. S2CID   30641527.
  3. ↑ Wolf, Jeffrey S.; Boyev, Kestutis P.; Manokey, Brenda J.; Mattox, Douglas E. (1999). "Success of the modified epley maneuver in treating benign paroxysmal positional vertigo". The Laryngoscope. 109 (6): 900–3. doi:10.1097/00005537-199906000-00011. PMID   10369279. S2CID   40144383.
  4. ↑ Epley, JM (1980). "New dimensions of benign paroxysmal positional vertigo". Otolaryngology–Head and Neck Surgery . 88 (5): 599–605. doi:10.1177/019459988008800514. PMID   7443266. S2CID   19628335.
  5. 1 2 3 4 5 Parnes, LS; Agrawal, SK; Atlas, J (2003). "Diagnosis and management of benign paroxysmal positional vertigo (BPPV)". CMAJ. 169 (7): 681–93. PMC   202288 . PMID   14517129.
  6. ↑ Hilton, Malcolm P.; Pinder, Darren K. (December 8, 2014). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". The Cochrane Database of Systematic Reviews (12): CD003162. doi:10.1002/14651858.CD003162.pub3. ISSN   1469-493X. PMC   11214163 . PMID   25485940.
  7. ↑ Schubert, Michael C. (2007). "Vestibular Disorders". In O'Sullivan, Susan B.; Schmitz, Thomas J. (eds.). Physical Rehabilitation (5th ed.). Philadelphia: F.A. Davis. pp. 999–1029. ISBN   978-0-8036-1247-1.
  8. ↑ Herdman, S. (2000). "Vestibular rehabilitation". Physical therapy diagnosis for vestibular disorders (3rd ed.). Philadelphia: F. A. Davis Company. pp. 228–308.
  9. ↑ Smouha, Eric E. (1997). "Time Course of Recovery After Epley Maneuvers for Benign Paroxysmal Positional Vertigo". The Laryngoscope. 107 (2): 187–91. doi:10.1097/00005537-199702000-00009. PMID   9023241. S2CID   26191334.
  10. ↑ Otsuka, Koji; Suzuki, Mamoru; Shimizu, Shigetaka; Konomi, Ujimoto; Inagaki, Taro; Iimura, Yoichi; Hayashi, Mami; Ogawa, Yasuo (2010). "Model experiments of otoconia stability after canalith repositioning procedure of BPPV". Acta Oto-Laryngologica. 130 (7): 804–9. doi:10.3109/00016480903456318. PMID   20095871. S2CID   30972133.
  11. ↑ "John M. Epley, M.D. [Obituary]". The Oregonian. August 4, 2019.
Listen to this article (6 minutes)
Sound-icon.svg
This audio file was created from a revision of this article dated 25 September 2019 (2019-09-25), and does not reflect subsequent edits.
(Audio help  · More spoken articles)
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.