ANNALS OF EMERGENCY MEDICINE SEPTEMBER 2011

Systematic Review SnapshotClinical SynopsisTAKE-HOME MESSAGE

The Epley maneuver is a very effective treatment for benign paroxysmal

positional vertigo.

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METHODS

DATA SOURCESMEDLINE, EMBASE, and CINAHLfrom 1966 through September2009 were searched; bibliogra-phies of identified articles werescanned for additional relevantarticles.

STUDY SELECTIONRandomized controlled trials andquasirandomized trials assessingthe effectiveness of the canalithrepositioning procedure (ie, Epleymaneuver) in patients with benignparoxysmal positional vertigowere reviewed by 2 authors, anda third author helped to resolvediscrepancies. Only studies re-porting outcome measurement atgreater than 24 hours after theintervention were included.

DATA EXTRACTION ANDSYNTHESISA data collection form that in-cluded methodological quality cri-teria was completed for eachstudy. Only randomized con-trolled trials were considered formeta-analysis with plans to reportoutcomes as odds ratios with95% confidence intervals.

286 Annals of Emergency Medicine

Is the Canalith Repositioning ManeuverEffective in the Acute Management ofBenign Positional Vertigo?EBEM CommentatorMichael D. Brown, MD, MScDivision of Emergency MedicineMichigan State University College of Human Medicine

Results

Results of the 2 included randomizedcontrolled trials.

Study (N)* OR (95% CI) NNT (95% CI)†

Lynn1 (33) 22 (3.4–142) 1.6 (1.0–2.3)Von Brevern2

(66)37 (8.8–159) 1.4 (1.1–1.7)

OR, Odds ratio; CI, confidence interval; NNT, num-ber needed to treat.*N�number of patients included in trial.†Calculated with Confidence Interval Analysis(version 2.1.2; University of Southampton,Southampton, UK).

Of the 10 studies meeting the inclu-sion criteria, only 2 were randomizedcontrolled trials. Therefore, the au-thors were unable to conduct a meta-analysis. These 2 randomized con-trolled trials were considered highquality, with adequate reporting ofrandomization, concealment of allo-cation, and blinding of patients andthose measuring outcomes; however,neither trial conducted an intention-to-treat analysis.1,2

Commentary

Based on a national sample of Inter-national Classification of Diseases,

Ninth Revision code data, it appears a

hat patients who receive a diagnosisf a vestibular condition frequentlyo not receive optimal emergency de-artment (ED) management.3 Patientsith benign paroxysmal positional

ertigo typically present with epi-odes of dizziness triggered by posi-ional changes that last less than 1inute.4 The results of this system-

tic review indicate that when theseypes of patients present to the ED, anttempt at the canalith repositioninganeuver is appropriate. Although

he results of the 2 randomized con-rolled trials are imprecise, the mag-itude of effect was large. The onlyrial published in the emergency med-cine literature that passed the sys-ematic review literature screen wasxcluded after full text review; therial was stopped early after only 11ubjects were enrolled in each armecause of an interim analysis demon-trating a profound benefit.5 Thealue of recommending restricted ac-ivity at discharge remains uncertain;ne of the randomized controlled tri-ls restricted activity after the inter-ention1 but the other did not.2

iven that there is no financial cost

ssociated with the Epley maneuver

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Systematic Review Snapshot

and the procedure requires only afew minutes to perform, emergencyphysicians should use this techniquefor patients with benign paroxysmalpositional vertigo.

1. Lynn S, Pool A, Rose D, et al.Randomized trial of the canalithrepositioning procedure. Otolaryngol HeadNeck Surg. 1995;113:712-720.

2. von Brevern M, Seelig T, Radtke A, et al.Short-term efficacy of Epley’s manoeuvre:a double-blind randomised trial. J NeurolNeurosurg Psychiatry. 2006;77:980-982.

3. Newman-Toker DE, Camargo JCA, Hsieh

Y-H, et al. Disconnect between charted

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vestibular diagnoses and emergencydepartment management decisions: across-sectional analysis from a nationallyrepresentative sample. Acad Emerg Med.2009;16:970-977.

4. Kerber KA. Vertigo and dizziness in theemergency department. Emerg Med ClinNorth Am. 2009;27:39-50.

5. Chang AK, Schoeman G, Hill M. Arandomized clinical trial to assess theefficacy of the Epley maneuver in thetreatment of acute benign positionalvertigo. Acad Emerg Med. 2004;11:918-924.

This is a clinical synopsis, a regular feature

of the Annals’ Systematic Review Snapshot E

SRS) series. The source for this systematiceview snapshot is: Helminski JO, Zee DS,anssen I, et al. Effectiveness of particle re-ositioning maneuvers in the treatment ofenign paroxysmal positional vertigo: a sys-ematic review. Phys Ther. 2009;90:663-678.OI:10.2522/ptj.20090071.

ystematic Review Author Contactanet O. Helminski, PT, PhDepartment of Physical Therapyidwestern Universityowners Grove, IL

-mail: jhelmi@midwestern.edu

Annals of Emergency Medicine 287