In this video I’m going to show you the modified Epley maneuver as a treatment for Benign paroxysmal positional vertigo from the posterior semicircular canals Get our very own Assessment E-Book and mobile app! Links are in the video description. Hi and welcome back to Physiotutors. Benign paroxysmal positional vertigo abbreviated as BPPV is the most common inner ear problem and cause of vertigo or false sense of spinning. Common causes are head trauma or ear infections. Although most cases appear to be idiopathic BPPV can be caused by debris in the semicircular canal of the ear which continues to move after the head has stopped moving. This causes ongoing movement that conflicts with other sensory information. The semicircular canals are filled with a fluid called endolymph. The main sense organ in each canal is called the crista which is stimulated by movement of the cupula. Head movement causes relative movement of the endolymph in the semicircular canal which bends the cupula and the embedded hairs of the hair cells and cause stimulation of the relevant vestibular nerve. The cause of BPPV is believed to be canalithiasis affecting the posterior semicircular canal in 85 to 95 % of all cases. In canalithiasis free-floating debris in the semicircular canal is hypothesized to act like a plunger causing continuing movement of the endolymph even after had movement has ceased. This causes movement of the cupula and bending of the hairs of the hair cells and provokes vertigo. Around 20% of BPPV cases are said to resolve within four weeks and up to 50% up to 3 months without treatment but recurrence is reported between 10 to 18% after one year. The modified Epley maneuver involves a series of four movements of head and body in order to move the debris out of the posterior semicircular canal In a Cochrane review from 2014 Hilton et al. found that the Epley maneuver was more effective than sham maneuvers or control. There was no difference when the Epley was compared to the Semont or Gans maneuver that you can watch by click in the top right corner. The chance of success in this review was described to be as high as 80%. Be aware that the Epley maneuver can lead to nausea which was reported in 17 to 32% of patients. So make sure you have a bucket at hand in case your patient might need it The patient should also be counseled that his symptoms of vertigo will be reproduced. On top of that make sure that the patient is able to tolerate neck movement. To perform the modified Epley maneuver have your patients sit on the treatment bench in long said with a pillow on the table that will make sure that the patient’s head is extended to 20° in a second. Rotate the patient’s had 45° to the right in order to perform the maneuver for the right posterior semicircular canal. So if your Dix-Hallpike test was positive in this position, this is how you start. The steps are an exact mirror for the left side. Now take the patient backwards in a quick movement so that your patient’s head is still rotated and extended to 20° by the pillow. Maintain this position for 20-30 seconds. Next quickly turn your patient’s head 90° towards the unaffected side and hold this position for another 20 seconds Afterwards have your patient roll onto his left shoulder and quickly turn his head a further 90° so that his head is facing down in a 45° angle. Again, hold this position for 20-30 seconds. Afterwards bring the patient into the upright sitting position to complete the maneuver. A meta-analysis from the Devaiah et al. from the year 2010 showed that post maneuver restrictions are not necessary as they have not shown any significant benefit compared to no restrictions. The literature demonstrated beneficial effects of multiple treatment sessions for patients with persistent nystagmus following the initial manoeuvre. Be aware that canal conversion from the posterior into the lateral semicircular canal occurs in 6-7% of those treated with canalith repositioning procedures. Therefore it is important to recognize this canal variant of BPPV as well. Alright, this was our video on the Epley maneuver for posterior semicircular BPPV. If you suspect that your patient has lateral canal BPPV, you will have to assess them with the Supine Head Roll test which you can watch by a click on the video right next to me. At last, thank you very much for watching! Please click on ‘like’ button if you enjoyed this video, subscribe to our channel and turn on the notifications in order not to miss any new videos! This was Kai for Physiotutors. I’ll see you in the next video. Bye!

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