Canalith Repositioning Procedure for Vertigo: Active treatment of BPPV

Update — in my other posts read more about Benign Paroxysmal Positional Vertigo

and Home care of vertigo


Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness, most often experienced when patients lies down.

Because BPPV is not intrinsically life threatening and symptoms are usually self limiting patient is usually kept under watchful wait but as BPPV can last for much longer than 2 months, it is better to treat it actively by Epley maneuvers or Semont Maneuver. The Semont and Epley maneuvers may improve or cure benign paroxysmal positional vertigo (BPPV) with only one procedure however some people may need multiple sittings.

CRP / Epley maneuver/  Canalith repositioning procedure


The Canalith Repositioning Procedure (CRP) or epley’s maneuver is a rehabilitation treatment for Benign positional vertigo.  CRP is very effective, with an approximate cure rate of 80%. The recurrence rate for BPPV after these maneuvers is low. However, in some instances additional treatment may be necessary.

Canalith/otolith/or otoconia are small crystals of calcium carbonate attached to the otolithic membrane in the utricle of the inner ear. Because of trauma, infection, or aging, canaliths can detach from the utricle and collect within the semicircular canals. Here these canaliths shift with the head movement  and stimulate sensitive nerve endings to cause dizziness.

Epley’s maneuvers involve a series of specifically patterned head and trunk movements performed by a trained professional. This head position change, moves the canaliths from the problematic location in one of the semicircular canal to the utricle.

Procedure: The procedure takes approximately 20-30 minutes.

You will be placed on a table and then laid back with your head hanging over the end of the table.
If you have a “positive” response in this position you will then be moved through the procedure.

A. Patient is placed in sitting position on the edge of the examination table (Position A).

B. Head is rotated 45° towards the affected ear, and the patient is swiftly placed in lying position with the head hanging 30° below the horizontal over the table edge (Position B). Positive response (primary stage nystagmus) is observed position is maintained for 1-2 minutes.

C. The head is rotated 90° towards the opposite ear while maintaining the head hanging position. (Position C)

D. Patient is turned further 90° towards the unaffected side to face the floor. (Position D)

The patient’s eyes are observed for secondary-stage nystagmus, it should be in the same direction as the primary-stage nystagmus.

E. Position is maintained for 30 to 60 seconds, and then again laced in sitting position (Position E). Upon sitting, there should be no vertigo or nystagmus in a successful maneuver.

Instructions Following the Canalith Repositioning Procedure

Wait for 10 minutes after the maneuver is performed before going home. Don’t drive yourself home.

For first 48 hours

  1. Do not tip your head up or down or bend at the waist. Use of the cervical collar will help prevent you from tipping your chin down.
  2. Do not visit the places that require you to lie down or tilt your head (hairdresser, dentist, chiropractor or barber).
  3. Avoid tipping your head up or down when brushing teeth, shaving or washing your hair.
  4. Sit down and get up from chairs while keeping your back straight, without bending forward and avoid tilting your head forward.
  5. Housework such as cooking or cleaning should be avoided for the next 48 hours.
  • Do Not Lie Flat in Bed:

Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle) by using a recliner chair or by using pillows arranged on a couch

The Following Week:

  • Do Not Sleep on your treated side
  • Use two pillows when you sleep.
  • Avoid sleeping on the “bad” side.
  • Don’t turn your head far up or far down

(Like head extended positions at the beauty parlor, dentist’s office, and while undergoing minor surgery).

  • No “sit-ups” for at least one week and no “crawl” swimming.

After 1 week you can resume your daily activities without any restrictions. Move around as you wish.

Update–

Contraindications to perform Epley Maneuver

  • Unstable heart disease
  • High grade carotid stenosis,
  • CNS disease (stroke or Transient Ischemic Attack),
  • Physical limitation– neck disease (rheumatoid arthritis, cervical radiculopathies, ankylosing spondylitis, cervical spine fracture or surgery)
  • Pregnant women beyond the 24th week of pregnancy

Semont Maneuver

The Semont maneuver (liberatory” maneuver) involves a procedure whereby the patient is quickly moved from lying on one side to lying on the other side.

© Liberatory manoeuvre of Semont (right ear)Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693.

Position 1. Patient is made to sit on the examination table with legs hanging over the edge and head turned 45 degrees horizontally towards the unaffected ear.

Position 2. While maintaining head rotation patient’s upper body is swiftly moved to side lying position on the affected side with head resting on examination table and nose pointed upwards. Position is maintained for 3 minutes or till vertigo and nystagmus subsides. This step moves the debris to the apex.

Position 3. Patient is rapidly moved through the sitting position (Position 1) to lying on the opposite or unaffected side (maintaining same head rotation) with nose pointed to the ground. Position is again maintained for 3 minutes or till the vertigo and nystagmus subsides. This maneuver moves the debris towards exit of the canal.

Idea is to move the debris into the utricle where it will no longer cause vertigo.

Semont maneuver is 90% effective after 4 treatment sessions

Update — Next post–Read more about BPPV (Spinning world–Benign Paroxysmal Positional Vertigo)

and Home care of Vertigo

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