The Epley maneuver or repositioning maneuver is a maneuver used by medical professionals to treat one common cause of

vertigo Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties w ...

benign paroxysmal positional vertigo 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. * T ...

(BPPV) of the posterior or anterior canals of the ear. The maneuver works by allowing free-floating particles, displaced

otoconia An otolith ( grc-gre, ὠτο-, ' ear + , ', a stone), also called statoconium or otoconium or statolith, is a calcium carbonate structure in the saccule or utricle of the inner ear, specifically in the vestibular system of vertebrates. The sa ...

, from the affected

semicircular canal In mathematics (and more specifically geometry), a semicircle is a one-dimensional locus of points that forms half of a circle. The full arc of a semicircle always measures 180° (equivalently, radians, or a half-turn). It has only one line of ...

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. The maneuver was developed by the physician, John M. Epley, and was first described in 1980. 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. The modified procedure has become that now described generally 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.

Sequence of positions

The following sequence of positions describes the Epley maneuver: # The

patient A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health c ...

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 The Dix–Hallpike test — or Nylén–Bárány test — is a diagnostic maneuver from the group of rotation tests used to identify benign paroxysmal positional vertigo (BPPV). Procedure When performing the Dix–Hallpike test, patients are lowe ...

. # 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. # The

clinician A clinician is a health care professional typically employed at a skilled nursing facility or clinic. Clinicians work directly with patients rather than in a laboratory or as a researcher. A clinician may diagnose, treat, and otherwise care for pa ...

observes the patient's eyes for “primary stage”

nystagmus Nystagmus is a condition of involuntary (or voluntary, in some cases) eye movement. Infants 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. Due to the invol ...

. # The patient remains in this position for approximately 1–2 minutes. # 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. # The patient remains in this position for approximately 1–2 minutes. # 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. # 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). # The patient remains in this position for approximately 1–2 minutes. # Finally, the patient is slowly brought up to an upright sitting posture, while maintaining the 45-degree rotation of the head. # 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 Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness. Dizziness is a common medical c ...

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. 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. 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) and is well tolerated by patients.

Background information

The goal of an Epley maneuver is to restore the equilibrium of the

vestibular system 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 ...

, more specifically, to the semicircular canals, in order to treat the symptoms associated with

BPPV 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. * T ...

. There is compelling evidence that free-floating

, probably displaced from the otolithic membrane in the utricle are the main cause of this disequilibrium. Recent pathological findings also suggest that the displaced otoconia typically settle in the posterior semicircular canal in the cupula of the

ampulla An ampulla (; ) was, in Ancient Rome, a small round vessel, usually made of glass and with two handles, used for sacred purposes. The word is used of these in archaeology, and of later flasks, often handle-less and much flatter, for holy water or ...

and render it sensitive to gravity. The cupula move in relation to acceleration of the head during rotary movements and signal to the brain via

action potentials An action potential occurs when the membrane potential of a specific cell location rapidly rises and falls. This depolarization then causes adjacent locations to similarly depolarize. Action potentials occur in several types of animal cells, c ...

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

associated with BPPV. 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. 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

(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. In 1957, John M. Epley received his M.D. degree from the

University of Oregon Medical School Oregon Health & Science University (OHSU) is a public research university focusing primarily on health sciences with a main campus, including two hospitals, in Portland, Oregon. The institution was founded in 1887 as the University of Oregon Med ...

(now

Oregon Health Sciences University Oregon Health & Science University (OHSU) is a public research university focusing primarily on health sciences with a main campus, including two hospitals, in Portland, Oregon. The institution was founded in 1887 as the University of Oregon Medi ...

). While a resident at

Stanford Medical School Stanford University School of Medicine is the medical school of Stanford University and is located in Stanford, California. It traces its roots to the Medical Department of the University of the Pacific, founded in San Francisco in 1858. This ...

he conducted original research on the first multichannel cochlear implant. He developed his BPPV technique in 1979. He died July 31, 2019.

References

External links

Video demonstration – "Epley maneuver" (no sound)
(0:40

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)
Video demonstration – "Epley's maneuver" (with narration)
(0:45