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Epley Canalith Repositioning Procedure (CRP)

Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Epley Maneuver for right posterior canal BPPV: 

Begin with the patient’s head turned 45 degrees toward the affected side.

Bring to a supine position with the head turned toward the affected side and hanging 20°.

Rotate the patient’s head 90 degrees toward the unaffected side.

Guide the patient to the side lying position with their nose pointing to the ground.

While keeping the head in 45°, tucked position,
return the patient to a seated position.

Helpful Hints:

  • It is most helpful to utilize Frenzel lenses or VNG while performing CRP. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight torsional nystagmus.
  • Before performing any positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine
  • If neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
  • Efficacy of the procedure is increased to >90% if CRP is performed twice in rapid succession
  • It is not unusual for the patient to lose postural control at the completion of the procedure due to the otoconia briskly falling within the cupula. It is vital that the examiner is in a stance that will provide postural support to the patient.
  • It is important to watch for changes in the nystagmus upon completion of the procedure: a reversal of nystagmus indicates that the otoconia fell back into the canal; an upbeat nystagmus indicates that the otoconia fell back into the cupula.

Procedure:

  • Begin with the patient sitting length-wise on the examination table
  • Place the Frenzel/VNG goggles on the patient
  • Have the patient turn his head to a 45o angle toward the side that you are going to treat (the affected side)
  • While maintaining the 45o head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20o. IT IS IMPERATIVE TO PROVIDE CERVIAL SUPPORT DURING THIS PORTION OF THE PROCEDURE.
  • Hold this position for 30-60 seconds
  • Maintain the 20o head extension and rotate the patient’s head 90o toward the unaffected side so that the patient’s head is approximately 45o toward the unaffected side
  • Hold this position for 30-60 seconds
  • While still maintaining the 45o head position, guide the patient into a side-lying position on the shoulder of the unaffected side. The patient’s nose should be pointed toward the floor.
  • Hold this position for 30-60 seconds
  • Instruct the patient to tuck his chin and maintain the 45o head position
  • Guide the patient back into a sitting position while ensuring that the patient’s head remains at the 45o angle and the chin remains tucked

**Refer to the attachment in attempting to diagnose affected ear and canal.

References:

  • Epley J. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404
  • Honrubia V, Baloh RW, Harris MR, et al. Paroxysmal positional vertigo syndrome. Am J Otol. 1999;20:465-470
  • Sherman D, Massoud EA. Treatment outcomes of benign paroxysmal positional vertigo. J Otolaryngol 2001;30:295-299.

CRP in the Treatment of BPPV

Posterior Canalithiasis:

  • Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side) that is less than one minute in duration
  • Recommended treatment is the Epley Maneuver of the affected side
  • Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises

Posterior Cupulothiasis:

  • Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side) that is greater than one minute in duration
  • Recommended treatment is the Semont Liberatory Maneuver
  • Alternative treatments might include Brandt-Daroff Exercises or the Epley CRP

Anterior Canalathiasis:

  • Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side) that is less than one minute in duration
  • Recommended treatment is the Epley CRP performed on the opposite side of the affected ear
  • Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises

Anterior Cupulothiasis:

  • Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side) that is greater than one minute in duration
  • Recommended treatment is the Semont Liberatory Maneuver
  • Alternative treatments might include Brandt-Daroff Exercises or the Epley CRP
March 2017
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