Professional Documents
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clinical practice
Caren G. Solomon, M.D., M.P.H., Editor
This Journal feature begins with a case vignette highlighting a common clinical problem.
Evidence supporting various strategies is then presented, followed by a review of formal guidelines,
when they exist. The article ends with the authors’ clinical recommendations.
From the Department of Neurology, A 58-year-old woman seeks care from her primary physician after the occurrence of
Seoul National University College of sudden vertigo and imbalance with nausea and vomiting, which began that morning
Medicine, Seoul National University Bun
dang Hospital, Seongnam, South Korea when she got out of bed. The vertigo lasted less than a minute but recurred when she
(J.-S.K.); and the Departments of Neu lay back down in bed, rolled over in bed, or got up again. She reports no tinnitus or
rology, Otolaryngology–Head and Neck hearing loss. How should this patient be evaluated and treated?
Surgery, Neuroscience and Ophthalmology,
Johns Hopkins University School of Medi-
cine, Baltimore (D.S.Z.). Address reprint The Cl inic a l Probl em
requests to Dr. Zee at the Department
of Neurology, Johns Hopkins Hospital,
600 N. Wolfe St., Baltimore, MD 21287, or Benign paroxysmal positional vertigo (BPPV) is by far the most common type of
at dzee@jhu.edu. vertigo, with a reported prevalence between 10.7 and 64.0 cases per 100,000 popu-
lation and a lifetime prevalence of 2.4%.1,2 The condition is characterized by brief
This article was last updated on March 28,
2014, at NEJM.org. spinning sensations, usually lasting less than 1 minute, which are generally induced
by a change in head position with respect to gravity.3,4 Vertigo typically develops
N Engl J Med 2014;370:1138-47.
DOI: 10.1056/NEJMcp1309481 when a patient gets in or out of bed, rolls over in bed, tilts the head back, or bends
Copyright © 2014 Massachusetts Medical Society. forward.3 Even though patients with BPPV occasionally report persistent dizziness
and imbalance, a careful history taking almost always reveals that their symptoms
are worse with changes in head position.4 Many patients also have nausea, some-
times with vomiting. Attacks of BPPV usually do not have a known cause, although
cases may be associated with head trauma, a prolonged recumbent position (e.g., at
a dentist’s office or hair salon), or various disorders of the inner ear.3 Spontaneous
remissions and recurrences are frequent; the annual rate of recurrence is approxi-
mately 15%.5 Patients with BPPV are at increased risk for falls and impairment in
An audio version the performance of daily activities.6
of this article is The prevalence of idiopathic BPPV is increased among elderly persons and among
available at women, with peak onset between 50 and 60 years of age and a female-to-male ratio
NEJM.org
of 2:1 to 3:1.2,3 BPPV has also been reported to be associated with osteopenia or osteo
porosis and with decreased serum levels of vitamin D — associations that are not
explained by age or sex.7,8 The fundamental pathophysiological process in BPPV in-
volves dislodged otoconia from the macula of the utricular otolith that enter the
semicircular canals. When there is a change in the static position of the head with
respect to gravity, the otolithic debris moves to a new position within the semi
circular canals, leading to a false sense of rotation. BPPV usually arises from the
posterior semicircular canal, which is the most gravity-dependent canal; this type
of BPPV accounts for 60 to 90% of all cases.4 However, the proportion of patients
with BPPV that involves the horizontal semicircular canal may have been under
estimated, since involvement at this site is more likely to remit spontaneously than
involvement in the posterior semicircular canal.9 BPPV rarely involves the anterior
semicircular canal, probably because of its uppermost position in the labyrinth,
where otolithic debris is unlikely to become trapped.10
• BPPV involving the posterior canal (the most common type) is diagnosed on the basis of nystagmus
beating in an upward and torsional direction, with the top poles of the eyes beating toward the lower
ear, as observed when the patient is lying on one side during the Dix–Hallpike maneuver.
• BPPV involving the horizontal canal is characterized by nystagmus that is either geotropic (beating
toward the ground) or apogeotropic (beating toward the ceiling) when the head is turned to either side
while the patient is in a supine position.
• Canalith-repositioning maneuvers (e.g., Epley’s and Semont’s maneuvers for the posterior canal) are
effective treatments for BPPV.
Diagnosis
S t r ategie s a nd E v idence
Physical examination reveals positional nystagmus
BPPV must be distinguished from other, more se- in more than 70% of patients with BPPV.12 This
rious causes of acute or episodic vertigo (Table 1). finding is elicited by performing specific maneu-
A history taking and neurologic examination vers, depending on which canal is affected.
often allow for differentiation among stroke,
vestibular neuritis, and BPPV. The examination Posterior Semicircular Canal
should include the testing of eye movements for In patients with BPPV that involves the posterior
sustained nystagmus, vertical ocular misalign- canal, nystagmus is typically induced with the
ment, and a pattern of vestibular responses that use of the Dix–Hallpike maneuver (Table 2 and
is suggestive of a central cause. Such testing has Fig. 1, and Video 1).13 When there is movement of
been reported to be more accurate for the diag- otolithic debris (canalolithiasis) in the posterior
nosis of stroke than computed tomography or canal away from the cupula, the endolymph flows
early use of magnetic resonance imaging.10,11 away from the cupula, stimulating the posterior
The diagnosis of BPPV is supported if changes in canal. The resulting nystagmus is upward-beating
head position with respect to gravity provoke the and torsional, with the top poles of the eyes beating
symptoms and elicit the patterns characteristic toward the ear in the lower position (as the patient’s
of BPPV. Because most physicians are not famil- head is turned to one side) (Video 1).13 The nystag-
iar with the precise anatomical relationships of mus usually develops after a brief latency period
the semicircular canals in the skull, it can be a (2 to 5 seconds), resolves within 1 minute (typi-
challenge to interpret the different patterns of cally within 30 seconds), and reverses direction
positional nystagmus and perform the correct when the patient sits up.13 With repeated testing,
maneuvers. (Videos available with the full text of the nystagmus diminishes owing to fatigability.13
this article at NEJM.org show the patterns of If the otoconia become attached to the cupula Videos showing
nystagmus that are diagnostic of the two most (cupulolithiasis), the evoked nystagmus is simi- patterns of
common types of BPPV and demonstrate the lar to that observed in canalolithiasis but is usu- nystagmus
and treatment
movements of the body that should be performed ally longer in duration.14
maneuvers are
to treat each type.) A positive response to the Dix–Hallpike ma- available at
BPPV sometimes involves multiple canals in neuver, in which the nystagmus beats in the NEJM.org
one ear or is bilateral, making it difficult to correct direction, is the standard for diagnosing
identify the patterns of nystagmus and choose BPPV involving the posterior canal. However, ap-
the best treatment. Generally, such cases should proximately one fourth of symptomatic patients
be referred to a specialist, as should cases of have little or no nystagmus. Treating these pa-
positional downbeat nystagmus and cases that tients may still be beneficial if their symptoms
are resistant to treatment. conform to the usual clinical picture.12
† In the head-impulse test, the result is considered abnormal when a corrective movement (saccade) is required to maintain straight-ahead fixation after the head has been rotated to the side.11
Neurologic symptoms or signs may in-
Recent inciting event possible (e.g., re-
abnormal†
either toward the ground (geotropic nystagmus,
Video 2)9,15 or toward the ceiling (apogeotropic
nyst agmus, Video 3).16
Proper treatment of BPPV involving the hori-
zontal canal requires knowledge of which ear is
Occasional
None
Treatment
BPPV typically resolves without treatment. A pro-
spective longitudinal study showed that the me-
tal canal
tional
Meniere’s disease
Stroke
Cause
Geotropic Supine head roll Head is turned approxi Geotropic (beats toward Barbecue rotation Head is rotated in three 90-degree
mately 90 degrees to the ground) increments, for a total of 270
each side while degrees, from affected ear down,
clinical pr actice
Downloaded from nejm.org on October 23, 2014. For personal use only. No other uses without permission.
Head-shaking Head is shaken from side to side at
approximately two cycles per
second for 15 seconds
* In ipsiversive nystagmus, the upper pole of the eyes beats toward the side of the affected (lower) ear.
† If the apogeotropic type of benign paroxysmal positional vertigo is converted to the geotropic type, treatment for the geotropic type should be provided.
1141
The n e w e ng l a n d j o u r na l of m e dic i n e
into the vestibule (Video 4), where they can be with patients treated with sham maneuvers and
resorbed.26 Each position should be maintained untreated controls, had significantly higher rates
until the induced nystagmus or vertigo dissipates, of improvement in symptoms (odds ratio, 4.4;
but always for at least 30 seconds.27 The success 95% confidence interval [CI], 2.6 to 7.4) and in
rate with Epley’s maneuver is about 80% after nystagmus (odds ratio, 6.4; 95% CI, 3.6 to 11.3).29
one session and increases to 92% with repetition Although some clinicians advocate the use of a
up to four times.28 A meta-analysis of five ran- hand-held vibrator on the mastoid of the involved
domized, controlled trials showed that patients side while Epley’s maneuver is being performed
with BPPV involving the posterior canal who or recommend that patients restrict movements
were treated with Epley’s maneuver, as compared of the head and body after treatment, there is
Figure 1. Use of the Dix–Hallpike Maneuver to Induce Nystagmus in Benign Paroxysmal Positional Vertigo Involving
the Right Posterior Semicircular Canal.
With the patient sitting upright (Panel A), the head is turned 45 degrees to the patient’s right (Panel B). The patient
is thenCmoved
O L O R from
F I G Uthe
R E sitting position to the supine position with the head hanging below the top end of the ex-
amination table at an angle of 20 degrees (Panel C). The resulting nystagmus would be upbeat and torsional, with
Draft 3 02/27/14
the top poles of the eyes beating toward the lower (right) ear (Panel D).
Author Zee
Fig # 1
Title
ME
DE
Artist SBL
1142 AUTHOR PLEASE NOTE:
n engl j med 370;12 nejm.org march 20, 2014
Figure has been redrawn and type has been reset
Please check carefully The New England Journal of Medicine
Downloaded
Issue date from nejm.org on October 23, 2014. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.
clinical pr actice
little evidence to support these suggestions.27,30,31 for BPPV involving the posterior canal, which oc-
However, it appears to be prudent for patients to curs in less than 5% of cases,39 is conversion to
sit still, in an upright position, for about 15 min- BPPV involving the horizontal canal. This condi-
utes after treatment and then to walk cautiously. tion can develop if the otoconial debris that moves
The pattern of nystagmus during Epley’s ma- out of the posterior canal falls into the horizontal
neuver helps to predict the success of treatment. canal. It can be treated with the same maneuvers
When the head is turned 90 degrees away from used for BPPV involving the horizontal canal
the affected side (after being placed in the initial (geotropic or apogeotropic), as described below.
Dix–Hallpike position), the positioning nystagmus
occasionally reappears (Video 4). According to Horizontal Canal
one report, all 99 patients whose nystagmus re- There are two types of BPPV involving the hori-
appeared in the same direction as the original zontal canal — one in which the nystagmus is
nystagmus had resolution after one or two ap- geotropic and one in which it is apogeotropic.
plications of Epley’s maneuver, whereas only 3 of The former is commonly treated with the barbe-
the 15 patients whose nystagmus shifted to the cue rotation. It consists of sequential 90-degree
opposite direction were cured.32 However, even rotations of the head, first toward the affected ear
in patients with nystagmus in the opposite di- and then toward the unaffected ear (Video 6).40
rection, enough debris may be removed from the With this maneuver, the otoconial debris mi-
posterior canal to relieve symptoms. grates and eventually exits the horizontal canal
The Semont maneuver can also be used to treat and passes into the vestibule. Another treatment,
BPPV involving the posterior canal (Fig. 3).33 To called Vannucchi’s forced prolonged position, in-
evacuate the particles, the patient is rapidly swung volves having the patient lie with the unaffected
at high acceleration through a 180-degree cart- ear down for approximately 12 hours.41 This treat-
wheel motion — from lying on the affected side ment is preferred for patients with severe symp-
to lying on the unaffected side — with the move- toms that worsen with sequential changes in po-
ment completed within 1.3 seconds (Video 5).34 sition and for those in whom it is unclear which
This maneuver can be used in lieu of Epley’s ear is affected.41 If lying on one side for a pro-
maneuver in patients who have difficulties ex- longed period is ineffective, the patient can try
tending the neck.35 As with Epley’s maneuver, nys lying on the other side for 12 hours. An alterna-
tagmus toward the affected side in the second tive treatment is Gufoni’s maneuver,42 in which
position of Semont’s maneuver is predictive of the patient quickly lies down on the side of the
successful treatment.36 Both Epley’s and Semont’s unaffected ear and remains in this position for
maneuvers may be repeated several times until 1 to 2 minutes, until the evoked nystagmus sub-
no nystagmus is elicited. Patients who require sides. The head is then quickly rotated 45 degrees
multiple treatments can be instructed to perform toward the floor and kept in this position for
the maneuvers at home. In a randomized, con- another 2 minutes, after which the patient re-
trolled trial, the success rate was 95% with self- sumes an upright position (Video 7).42
administration of Epley’s maneuver and 58% with In a prospective observational study involving
self-administration of Semont’s maneuver.37 Self- 60 patients, the effectiveness of Vannucchi’s forced
administered canalith-repositioning maneuvers prolonged position did not differ significantly
may be more effective when combined with guided from that of Gufoni’s maneuver; both were more
canalith-repositioning maneuvers performed at effective than the barbecue rotation after a sin-
a clinic.38 gle application (with success rates of 76% and
Nausea or vomiting and vertigo may occur dur- 89%, respectively, vs. 38%).43 A recent random-
ing these maneuvers, and many patients have a ized trial showed that both the barbeque rota-
sensation of being off-balance and transient dizzi- tion and Gufoni’s maneuver were more effective
ness with head motion for several days or more, than a sham maneuver (with success rates of
even after successful treatment. In some instanc- 68% and 61%, respectively, vs. 35%).44
es, a brief episode of vertigo occurs several min- BPPV involving the horizontal canal with apo-
utes after performance of the maneuver. Another geotropic nystagmus is attributed to otolithic
possible complication of the treatment maneuvers debris that is attached to the cupula (cupulo
COLOR FIGURE
Figure 3. Semont’s Repositioning Maneuver for Benign Paroxysmal Positional Vertigo Involving the Right Posterior Semicircular Canal.
The patient is asked to sit upright (Panel A) and then to lie on the side of the affected, right ear, with the head turned slightly to the left
COLOR FIGURE
(Panel B). The patient is then rapidly guided in a cartwheel pattern through the upright position to the other side, without a pause, with the head
remaining
Draft 3 turned slightly to the left (Panel C). Finally, the patient is seated and the head is returned to the neutral position (Panel D). Each posi-
02/27/14
tion should
Author Zee be maintained until the induced nystagmus and vertigo resolve, but always for a minimum of 2 minutes.
Fig # 3
Title
ME
DE of brief vertigo associated with paroxysmal up- cured with either maneuver at the first visit. How-
Artist SBL beat and torsional nystagmus is diagnostic of ever, the patient should be informed that BPPV
AUTHOR PLEASE NOTE:
BPPV involving the posterior canal (the most com- may recur and require retreatment.
Figure has been redrawn and type has been reset
mon type of BPPV). Given this finding, we recom-
Please check carefully
References
1. Bhattacharyya N, Baugh RF, Orvidas sitional vertigo. Otolaryngol Head Neck benign paroxysmal positional vertigo. In:
L, et al. Clinical practice guideline: benign Surg 2000;122:647-52. Bronstein A, ed. Oxford textbook of ver-
paroxysmal positional vertigo. Otolaryngol 6. Lopez-Escamez JA, Gamiz MJ, Fer- tigo and imbalance. Oxford, England: Ox-
Head Neck Surg 2008;139:Suppl 4:S47-S81. nandez-Perez A, Gomez-Fiñana M. Long- ford University Press, 2013:217-30.
2. von Brevern M, Radtke A, Lezius F, et term outcome and health-related quality 11. Kattah JC, Talkad AV, Wang DZ, Hsieh
al. Epidemiology of benign paroxysmal po- of life in benign paroxysmal positional YH, Newman-Toker DE. HINTS to diag-
sitional vertigo: a population based study. vertigo. Eur Arch Otorhinolaryngol 2005; nose stroke in the acute vestibular syn-
J Neurol Neurosurg Psychiatry 2007;78: 262:507-11. drome: three-step bedside oculomotor
710-5. 7. Jeong SH, Choi SH, Kim JY, Koo JW, examination more sensitive than early
3. Baloh RW, Honrubia V, Jacobson K. Kim HJ, Kim JS. Osteopenia and osteo MRI diffusion-weighted imaging. Stroke
Benign positional vertigo: clinical and ocu porosis in idiopathic benign positional 2009;40:3504-10.
lographic features in 240 cases. Neurology vertigo. Neurology 2009;72:1069-76. 12. Balatsouras DG, Korres SG. Subjective
1987;37:371-8. 8. Jeong SH, Kim JS, Shin JW, et al. De- benign paroxysmal positional vertigo. Oto
4. Furman JM, Cass SP. Benign paroxys- creased serum vitamin D in idiopathic laryngol Head Neck Surg 2012;146:98-103.
mal positional vertigo. N Engl J Med 1999; benign paroxysmal positional vertigo. 13. Dix MR, Hallpike CS. The pathology
341:1590-6. J Neurol 2013;260:832-8. symptomatology and diagnosis of certain
5. Nunez RA, Cass SP, Furman JM. 9. McClure JA. Horizontal canal BPV. common disorders of the vestibular sys-
Short- and long-term outcomes of canalith J Otolaryngol 1985;14:30-5. tem. Proc R Soc Med 1952;45:341-54.
repositioning for benign paroxysmal po- 10. Nuti D, Zee DS. Positional vertigo and 14. Steddin S, Ing D, Brandt T. Horizontal
canal benign paroxysmal positioning ver- ysmal positional vertigo. Otolaryngol Head KI. Self-treatment for benign paroxysmal
tigo (h-BPPV): transition of canalolithiasis Neck Surg 1992;107:399-404. positional vertigo of the posterior semi-
to cupulolithiasis. Ann Neurol 1996;40: 27. Fife TD, Iverson DJ, Lempert T, et al. circular canal. Neurology 2005;65:1299-
918-22. Practice parameter: therapies for benign 300.
15. Baloh RW, Jacobson K, Honrubia V. paroxysmal positional vertigo (an evidence- 39. Herdman SJ, Tusa RJ. Complications
Horizontal semicircular canal variant of based review): report of the Quality Stan- of the canalith repositioning procedure.
benign positional vertigo. Neurology 1993; dards Subcommittee of the American Arch Otolaryngol Head Neck Surg 1996;
43:2542-9. Academy of Neurology. Neurology 2008;70: 122:281-6.
16. Baloh RW, Yue Q, Jacobson KM, Hon- 2067-74. 40. Lempert T. Horizontal benign posi-
rubia V. Persistent direction-changing 28. Gordon CR, Gadoth N. Repeated vs tional vertigo. Neurology 1994;44:2213-4.
positional nystagmus: another variant of single physical maneuver in benign par- 41. Vannucchi P, Giannoni B, Pagnini P.
benign positional nystagmus? Neurology oxysmal positional vertigo. Acta Neurol Treatment of horizontal semicircular ca-
1995;45:1297-301. Scand 2004;110:166-9. nal benign paroxysmal positional vertigo.
17. Asprella Libonati G. Diagnostic and 29. Hilton M, Pinder D. The Epley (cana J Vestib Res 1997;7:1-6.
treatment strategy of lateral semicircular lith repositioning) manoeuvre for benign 42. Gufoni M, Mastrosimone L, Di Nasso
canal canalolithiasis. Acta Otorhinolaryn- paroxysmal positional vertigo. Cochrane F. Repositioning maneuver in benign par-
gol Ital 2005;25:277-83. Database Syst Rev 2004;2:CD003162. oxysmal vertigo of horizontal semicircu-
18. Han BI, Oh HJ, Kim JS. Nystagmus 30. Hunt WT, Zimmermann EF, Hilton lar canal. Acta Otorhinolaryngol Ital 1998;
while recumbent in horizontal canal be- MP. Modifications of the Epley (canalith 18:363-7. (In Italian.)
nign paroxysmal positional vertigo. Neu- repositioning) manoeuvre for posterior 43. Korres S, Riga MG, Xenellis J, Korres
rology 2006;66:706-10. canal benign paroxysmal positional ver- GS, Danielides V. Treatment of the hori-
19. Lee SH, Choi KD, Jeong SH, Oh YM, tigo (BPPV). Cochrane Database Syst Rev zontal semicircular canal canalithiasis:
Koo JW, Kim JS. Nystagmus during neck 2012;4:CD008675. pros and cons of the repositioning ma-
flexion in the pitch plane in benign par- 31. Devaiah AK, Andreoli S. Postmaneu- neuvers in a clinical study and critical re-
oxysmal positional vertigo involving the ver restrictions in benign paroxysmal po- view of the literature. Otol Neurotol 2011;
horizontal canal. J Neurol Sci 2007;256:75- sitional vertigo: an individual patient data 32:1302-8.
80. meta-analysis. Otolaryngol Head Neck Surg 44. Kim JS, Oh SY, Lee SH, et al. Random-
20. Choung YH, Shin YR, Kahng H, Park 2010;142:155-9. ized clinical trial for geotropic horizontal
K, Choi SJ. ‘Bow and lean test’ to deter- 32. Oh HJ, Kim JS, Han BI, Lim JG. Pre- canal benign paroxysmal positional ver-
mine the affected ear of horizontal canal dicting a successful treatment in posteri- tigo. Neurology 2012;79:700-7.
benign paroxysmal positional vertigo. or canal benign paroxysmal positional 45. Nuti D, Mandalà M, Salerni L. Lateral
L aryngoscope 2006;116:1776-81. vertigo. Neurology 2007;68:1219-22. canal paroxysmal positional vertigo revis-
21. Bertholon P, Bronstein AM, Davies 33. Semont A, Freyss G, Vitte E. Curing ited. Ann N Y Acad Sci 2009;1164:316-23.
RA, Rudge P, Thilo KV. Positional down the BPPV with a liberatory maneuver. Adv 46. Oh SY, Kim JS, Jeong SH, et al. Treat-
beating nystagmus in 50 patients: cere- Otorhinolaryngol 1988;42:290-3. ment of apogeotropic benign positional
bellar disorders and possible anterior 34. Faldon ME, Bronstein AM. Head ac- vertigo: comparison of therapeutic head-
semicircular canalithiasis. J Neurol Neu- celerations during particle repositioning shaking and modified Semont maneuver.
rosurg Psychiatry 2002;72:366-72. manoeuvres. Audiol Neurootol 2008;13: J Neurol 2009;256:1330-6.
22. Cambi J, Astore S, Mandalà M, Trabal- 345-56. 47. Casani AP, Vannucci G, Fattori B, Ber-
zini F, Nuti D. Natural course of positional 35. Mandalà M, Santoro GP, Asprella Li- rettini S. The treatment of horizontal ca-
down-beating nystagmus of peripheral ori- bonati G, et al. Double-blind randomized nal positional vertigo: our experience in
gin. J Neurol 2013;260:1489-96. trial on short-term efficacy of the Semont 66 cases. Laryngoscope 2002;112:172-8.
23. Imai T, Ito M, Takeda N, et al. Natural maneuver for the treatment of posterior 48. Ciniglio Appiani G, Catania G, Gagli
course of the remission of vertigo in pa- canal benign paroxysmal positional ver- ardi M, Cuiuli G. Repositioning maneuver
tients with benign paroxysmal positional tigo. J Neurol 2012;259:882-5. for the treatment of the apogeotropic
vertigo. Neurology 2005;64:920-1. 36. Soto-Varela A, Rossi-Izquierdo M, variant of horizontal canal benign parox-
24. Kerber KA, Burke JF, Skolarus LE, et al. Santos-Pérez S. Can we predict the effi- ysmal positional vertigo. Otol Neurotol
Use of BPPV processes in emergency depart- cacy of the Semont maneuver in the treat- 2005;26:257-60.
ment dizziness presentations: a population- ment of benign paroxysmal positional 49. Nuti D, Vannucchi P, Pagnini P. Be-
based study. Otolaryngol Head Neck Surg vertigo of the posterior semicircular ca- nign paroxysmal positional vertigo of the
2013;148:425-30. nal? Otol Neurotol 2011;32:1008-11. horizontal canal: a form of canalolithia-
25. Helminski JO, Zee DS, Janssen I, Hain 37. Radtke A, von Brevern M, Tiel-Wilck K, sis with variable clinical features. J Vestib
TC. Effectiveness of particle repositioning Mainz-Perchalla A, Neuhauser H, Lem- Res 1996;6:173-84.
maneuvers in the treatment of benign pert T. Self-treatment of benign paroxys- 50. Kim JS, Oh SY, Lee SH, et al. Random-
paroxysmal positional vertigo: a system- mal positional vertigo: Semont maneuver ized clinical trial for apogeotropic hori-
atic review. Phys Ther 2010;90:663-78. vs Epley procedure. Neurology 2004;63: zontal canal benign paroxysmal positional
26. Epley JM. The canalith repositioning 150-2. vertigo. Neurology 2012;78:159-66.
procedure: for treatment of benign parox- 38. Tanimoto H, Doi K, Katata K, Nibu Copyright © 2014 Massachusetts Medical Society.