Effectiveness of the Canalith Repositioning

Procedure in the Treatment of Benign Paroxysmal

Positional Vertigo
Janet O. Helminski
PHYS THER. Published online June 5, 2014
doi: 10.2522/ptj.20130239

The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/early/2014/06/04/ptj.20130239

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Running head: <LEAP> Case #24 Applying Evidence to a Patient With BPPV

<LEAP> Linking Evidence And Practice

Effectiveness of the Canalith Repositioning Procedure in the Treatment of Benign

Paroxysmal Positional Vertigo

Janet O. Helminski

J.O. Helminski, Physical Therapy, Midwestern University, 555 31st St, Downers Grove, IL

60515 (USA). Address all correspondence to Dr Helminski at: [email protected].

[Helminski JO. Effectiveness of the canalith repositioning procedure in the treatment of benign

paroxysmal positional vertigo. Phys Ther. 2014;94:xxx–xxx.]

© 2014 American Physical Therapy Association

Publish Ahead of Print: xxxx

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Accepted: May 26, 2014

Submitted: June 7, 2013

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<LEAP>  highlights  the  findings  and  application  of  Cochrane  reviews  and  other  evidence  pertinent  to  the  

practice  of  physical  therapy.  The  Cochrane  Library  is  a  respected  source  of  reliable  evidence  related  to  

health  care.  Cochrane  systematic  reviews  explore  the  evidence  for  and  against  the  effectiveness  and  

appropriateness  of  interventions—medications,  surgery,  education,  nutrition,  exercise—and  the  evidence  

for  and  against  the  use  of  diagnostic  tests  for  specific  conditions.  Cochrane  reviews  are  designed  to  

facilitate  the  decisions  of  clinicians,  patients,  and  others  in  health  care  by  providing  a  careful  review  and  

interpretation  of  research  studies  published  in  the  scientific  literature.1  Each  article  in  this  PTJ  series  

summarizes  a  Cochrane  review  or  other  scientific  evidence  on  a  single  topic  and  presents  clinical  

scenarios  based  on  real  patients  or  programs  to  illustrate  how  the  results  of  the  review  can  be  used  to  

directly  inform  clinical  decisions.  This  article  focuses  on  an  adult  patient  with  benign  paroxysmal  

positional  vertigo.

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Introduction

Benign Paroxysmal Positional Vertigo (BPPV) presents with brief periods of vertigo experienced

with a change in the position of the person’s head relative to gravity. BPPV is a mechanical

disorder of the inner ear caused by abnormal stimulation of one or more of the three semicircular

canals (Figure 1). The otoconia from the utricle dislodge and settle within one of the three

semicircular canals changing the fluid filled canal dynamics from detecting rotation of the canals

to detecting gravitation forces on the head. With BPPV, changing the plane of the involved

canal relative to gravity causes debris to settle to the lowest part of the canal, changing the fluid

pressure across the cupula, deflecting the hair cells, and generating the characteristic ocular

nystagmus with associated vertigo. There are three mechanisms of BPPV, the most common

being debris within the long arm of the canal called canalithiasis.1 Debris may also be found in

the short arm of the canal2 or attached to the cupula weighting the membrane called

cupulolithiasis.2 The most common canal involved is the posterior semicircular canal (PC).3

The diagnosis of BPPV is based on history and findings on positional testing.4,5 If patients

complain of vertigo with rolling in bed or getting out of bed, patients are 4.3 times more likely to

have BPPV.6 The Dix-Hallpike test7 and the Side-Lying test8 are the standard tests4,5 for

evaluating posterior canal BPPV. A comparison of the Dix-Hallpike test and Side-Lying test

found no significant difference between the two techniques.8 Frenzel lenses or video

oculography should be used to prevent suppression of ocular nystagmus. The diagnostic criteria

for posterior canal BPPV are vertigo associated with the characteristic nystagmus of torsional,

superior pole towards the lowermost ear - the involved ear, and upbeating9 with a 1-45 s latency

before the onset,10-12 duration of <60 s,13 and fatigue with repeated positioning.13 For the DHT,

the estimated sensitivity is 79% (95% confidence interval [CI]=65-94) and specificity is 75%

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(CI=33-100) and for the Side-Lying test, the estimated sensitivity is 90% (95% confidence

interval [CI]=79-100) and specificity is 75% (CI=34-100).14

Once identified, posterior canal BPPV may be effectively treated with a particle repositioning

maneuver such as the canalith repositioning maneuver (CRP) described by Epley.15 The canalith

repositioning maneuver is a series of four head positions designed to use the effects of gravity to

treat canalithiasis (Fig. 2A). With each head position, the debris settles to the lowest portion of

the canal moving the debris away from the ampulla, into the common crus, and then into the

utricle. With each change in position (steps 2-4), the movement of debris through the canal away

from the ampulla may create changes in pressure across the cupula resulting in the generation of

the same typical torsional and upbeating nystagmus predicting successful outcome of the

maneuver (Fig. 3A:video 1).16 If during the third and/or fourth step of the maneuver, the

movement of debris through the canal reverses direction, the debris moves towards the ampulla,

a reversal in direction of nystagmus may be observed predicting treatment failure (Fig. 3B).16

Video oculography should be used to monitor nystagmus in response to movement of debris

through the canals and to prevent suppression of nystagmus. The procedure is repeated a

minimum of three times within the treatment session. Repeating the CRP more than once is

significantly more effective than performing the CRP once within a treatment session.17

Acceptable modifications to the CRP as described by Epley include performance of the CRP

without mastoid vibration (thought to prevent debris from adhering to the canal walls) and self-

administration of the CRP.4,5 Short term outcome is the same for patients with and without post-

intervention positional and activity restrictions.18,19 But, a reduced number of treatment sessions

are required to produce a negative Dix-Hallpike test if post-intervention positional and activity

restrictions are maintained.20 To determine the results of the CRP, the Dix-Hallpike test should

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be performed optimally > 24 hours after treatment to avoid the effects of fatigue.21 Successful

outcome is defined as conversion from a positive to negative Dix-Hallpike test, no benign

paroxysmal positional nystagmus and associated vertigo.

A Cochrane systematic review by Hilton and Pinder22 examined the evidence to determine the

effectiveness of the CRP compared to other treatments available or no treatment for individuals

with posterior canal BPPV. This review is an update of a Cochrane Review first published in the

Cochrane Library in Issue 1, 2002 and then updated in 2004 and 2007. Randomized controlled

trials were included if participants were adults (> 16 years of age) with the clinical diagnosis of

posterior canal BPPV based on positive findings during the Dix-Hallpike test (observation of the

characteristic nystagmus and symptoms of associated vertigo). Trials compared the effectiveness

of the modified CRP (without the use of vibration) with a sham maneuver or an untreated

control. There was no evidence comparing the effectiveness of the CRP with other physical,

medical or surgical therapy for posterior canal BPPV. Follow-up ranged from <24 hours,21,23 to

1-2 weeks,24 to 1 month25,26 post-treatment. The primary outcomes included complete

resolution of symptoms and conversion from a positive to a negative Dix-Hallpike test, the only

objective physiological change resulting from treatment. The search date of the review was May

19, 2010. A summary of findings is found in Table 1.

Take-Home Message

The review reported the results of five randomized controlled trials involving 292 adults with a

clinical diagnosis of posterior canal BPPV based on history and positive findings on the Dix-

Hallpike test. The outcome of the CRP was compared to an untreated control26 in one study or a

sham treatment in the remaining 4 studies.21,23-25 The sham treatment consisted of lying on

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affected side for five minutes,24 lying in the first lateral position of the liberatory maneuver,25 or

CRP performed as if opposite ear affected.21,23 Two trials instructed subjects in post-intervention

restrictions24,25 and three trials had no post-intervention restrictions.21,23,26 The overall risk for

bias was graded low for four trials21,23-25 and unable to determine for 1 trial.26

Pooled data showed a statistically significant difference in symptom resolution and in conversion

from a positive to a negative Dix-Hallpike test in favor of the CRP.22 At short term follow-up

(less than one month), subjective symptom resolution for patients treated with the CRP were

32% to 80%,21,23-26 those obtained with the sham treatment were 10% to 34%,21,23-25 and that

obtained with the control was 35%.26 The pooled odds in favor of complete subjective symptom

resolution were 4.42 times higher (95% CI=2.62-7.44) with the CRP than with the sham

treatment/control.21,23-26 At short term follow-up, the success rates for patients treated with the

CRP who converted to a negative Dix-Hallpike test were 34% to 89%,21,23-26 those obtained with

the sham treatment were 10% to 38%,21,23-25 and that obtained with the control was 65%.26 The

magnitude of the effect of the CRP compared with that of the sham treatment/control was

significant in all five studies. The pooled odds in favor of conversion of positive to negative

Dix-Hallpike test were 6.40 times higher (95% CI=3.63-11.28) with the CRP than with the sham

treatment/control.21,23-26 The individual odds in favor of symptom resolution were variable

from 3.03 (95% CI=1.01-9.07) to 37.33 (95% CI=8.75-159.22). There were no reported adverse

effects or serious complications of treatment. Reported complications included inability to

tolerate positions due to cervical spine dysfunction,24 emesis during treatment,21,24 nausea,21 and

fainting.26

Case #00: CRP for Treatment of PC-BPPV

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Can the CRP help this patient?

“Dr. X” is a 40 year old female with a seven year history of episodic positional vertigo, the most

recent episode beginning seven days ago when she rolled over in bed and woke with severe

vertigo and nausea. She was evaluated by a neuro-otologist, diagnosed with BPPV, and referred

to outpatient physical therapy for vestibular rehabilitation. To differentiate between BPPV and

other causes of dizziness, the physical therapy evaluation consisted of completion of self-

reported participation questionnaires, a history, a neurologic screen, and positional testing. The

patient completed the Dizziness Handicapped Inventory,27 designed to evaluate self-perceived

handicap due to dizziness, and the Activities Balance Confidence (ABC) scale,28 designed to

evaluate self-perceived balance confidence in performing household and community activities

(Table 2). The patient reported constant nausea; vertigo when rolling in bed towards the right,

getting in and out of bed, bending forward, looking up, and moving her head rapidly; and

vomiting during the physician’s examination. She slept in bed propped upright on five pillows

to avoid provoking positions, experienced difficulty concentrating at work, and felt anxious. The

patient’s history and findings on the Dizziness Handicapped Inventory suggested severe BPPV

while the total score of the Dizziness Handicapped Inventory suggested severe 0suppression of

ocular nystagmus, the patient medicated with ondansetron(Zofran®) prior to the evaluation per

the physician’s order.

The neurologic screen was negative. She had no contraindications for further positional testing or

a particle repositioning maneuver. Functional outcome measures administered included the

Dynamic Gait Index,29 designed to evaluate postural stability during various walking tasks, and

Timed “Up & Go” Test30, a measurement of walking speed (Table 2). The Dix-Hallpike test was

performed with the use of video-oculography to avoid visual fixation that suppresses ocular

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nystagmus and to digitally record eye movements. The Dix-Hallpike test - left head hanging

position was negative. The right head hanging position was positive, a typical nystagmus,

counterclockwise torsional (superior pole of eye directed towards the lowermost ear) and

upbeating, was observed with a two second latency before onset of nystagmus, 21 s duration of

nystagmus, and 8/10 peak velocity of nystagmus (0 no nystagmus and 10 extreme nystagmus).

The patient complained of severe vertigo associated with nystagmus and became nauseous.

Upon return to the upright position, a strong downbeating nystagmus associated with vertigo and

disorientation to vertical was noted. History and findings on the Dix-Hallpike test suggested

BPPV involving the right posterior canal. The patient was identified as a good candidate for the

CRP for right posterior canal BPPV. The mechanism of BPPV and treatment options was

discussed with the patient. The patient was informed of potential treatment complications such

as a canal conversion (movement of debris into another canal), canal jam (movement of debris

from a wide to narrow portion of the canal resulting in plugging of the canal), further nausea,

emesis, and further imbalance. The patient understood that the treatment risks were minimal and

consented to treatment of right posterior canal BPPV with the right CRP.

Physical therapy intervention consisted of performance of the right CRP without the use of

mastoid vibration. Each position was maintained for the duration of the nystagmus in the second

step plus 20 seconds (Fig. 2A). Video-oculography was used to visualize nystagmus in each

position to monitor the treatment progress. To optimize effectiveness of the maneuver, three

cycles of the CRP were performed within one treatment session. During the first cycle, a

counterclockwise torsional and upbeating nystagmus was observed in the second, third, and

fourth steps suggesting movement of debris away from the right posterior canal ampulla and

successful treatment.16 The nystagmus was associated with vertigo. The patient felt nauseous

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but did not have emesis. During the second and third cycle of the CRP, no nystagmus was

observed and the patient did not complain of vertigo or nausea. Following the procedure, the

patient sat in the clinic for 20 minutes to allow debris to settle and to be supported if she

experienced sudden imbalance or vertigo. The patient was instructed in postural and activity

restrictions to minimize the number of treatment sessions. Dr. X was instructed to sleep on the

uninvolved side with the head elevated on a wedge made of three pillows and to avoid up and

down movements of the head for one week. She was given a handout describing the

mechanisms of BPPV, treatment options, post-treatment postural and activity restrictions, and

recurrence of BPPV. She was instructed to have someone drive her home.

The treatment results were evaluated at one week follow-up. Success was defined as no

subjective complaints of vertigo and conversion from a positive to negative Dix-Hallpike test.

Patient reported maintaining postural and activity restrictions and experiencing no episodes of

positional vertigo or symptoms of nausea during her daily routine. The total score on the

Dizziness Handicapped Inventory suggested no self-perceived handicap due to dizziness and the

total score on the Activities Balance Confidence (ABC) scale and Dynamic Gait Index suggested

no residual balance deficits (Table 2). Her speed of gait on the Timed “Up & Go” Test was

within normal limits for her age (Table 2). The Dix-Hallpike test was performed using video-

oculography. No nystagmus was observed and the patient did not complain of vertigo. Findings

suggested successful resolution of BPPV following treatment with the CRP. The patient was

educated in the probability of recurrence of BPPV and factors associated with recurrence.

Further intervention was not indicated.

How did the results of the Cochrane review apply to “Dr. X”?

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The physical therapist considered whether “Dr. X” would be a good candidate for the use of the

CRP to treat right posterior canal BPPV. Using the PICO (Patient, Intervention, Comparison,

Outcome) format, the clinician asked the question: Will a 40 year old woman diagnosed with

right PC-BPPV benefit from the CRP to resolve symptoms of vertigo and to convert from a

positive to a negative Dix-Hallpike test? Based on history and findings on the Dix-Hallpike test,

“Dr. X” had a diagnosis of right posterior canal BPPV. The results of the Cochrane review may

be applied directly to “Dr. X.” The participant population was a similar age and gender and had

similar symptoms of positional vertigo.

Our procedure matched the published protocols of articles described in the Cochrane review.

The CRP consisted of a series of four positions without the use of mastoid vibration.21,23-25 The

duration of each position was the duration of the nystagmus plus 20 seconds.24,25 Three cycles of

the CRP was performed and no nystagmus was observed during the second and third cycle. The

CRP is repeated until no nystagmus is observed or a maximum of five cycles is performed to

optimize success.21,24,25 Following the maneuver, the patient was instructed in postural and

activity restrictions with the exception of wearing a soft cervical collar24,25 to reduce the number

of treatment sessions required to produce a negative Dix-Hallpike test.

How well do the outcomes of the intervention provided to Dr. X match those suggested by

the systematic review?

Within one treatment session, Dr. X achieved her goal of resolution of all symptoms of vertigo

with her daily routine. The therapist achieved her goal of conversion from a positive to negative

Dix-Hallpike test with no subjective complaints of vertigo. Successful resolution of posterior

canal BPPV with one treatment session of the CRP is consistent with the reported Cochrane

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review findings.22 Following one treatment session, the average short-term success of the CRP

for complete resolution of symptoms ranged from 34% to 89%,21,23-26 with an average percent

of 57+18% and for conversion from a positive to negative Dix-Hallpike test ranged from 34% to

89%21,23-26 with an average percent of 72+23%.22

Dr. X’s perceived level of handicap due to dizziness and perceived level of balance confidence in

performing household and community activities returned to normal. Balance control during gait

activities and speed of gait all returned to an age appropriate level. Participation and functional

level goals were not included in the trials and therefore were not included in the Cochrane

review. Dr. X’s positive outcome exceeded those that were significant in the Cochrane review.

Can you apply the results of the systematic review to your own patients?

All 292 participants in the trials included in this Cochrane review were diagnosed with posterior

canal BPPV based on history and findings on the Dix-Hallpike Test. Following one treatment

session, the short-term success rate of the CRP for complete symptom resolution on average was

57+18% and for conversion from a positive to a negative Dix-Hallpike test was on average

72+23%.22 There were few reported adverse effects of treatment and no serious complications.

The only reported limitations were emesis and cervical dysfunction preventing positioning of the

head. The results of the Cochrane Review22 may be applied to patients diagnosed with posterior

canal BPPV. However, long-term following up was lacking in all of the trials. Therefore, there

is no good evidence that the CRP provides a long-term resolution of symptoms. At the time of

the search date, there was no good evidence comparing the CRP with other particle repositioning

maneuvers, medical intervention or surgical intervention for posterior canal BPPV.

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Two double-blinded randomized sham-controlled trials have assessed the short-term efficacy of

the liberatory maneuver an alternative particle repositioning maneuver in the treatment of

posterior canal BPPV31 (Figure 2B). At short term follow-up, subjective symptom resolution for

patients treated with the liberatory maneuver were 85%32 and 87%33 and those obtained with the

sham treatment were 0%33 and 14%.32 The presence of nystagmus in the same direction in the

second and third steps suggests successful treatment.34 Side effects included transient nausea,

vomiting, pallor, sweating, and loss of balance. 32,33 No trials have directly compared the

liberatory maneuver to the CRP.

Other treatments for PC-BPPV include Brandt-Daroff exercises, habituation exercises.35,36

Subsequent to the Cochrane review search date, two trials have compared the CRP to Brandt-

Daroff exercises, the Liberatory maneuver, and untreated control. At one week, the short term

success rate was 81%35 and 87%36 for the CRP, 25%35 and 35%36 for the Brand-Daroff

exercises, 53% for the liberatory maneuver, 36 and 15% for the untreated control.36 Brand-Daroff

exercises were as effective as a control at one week.36

What can be advised based on the results of this systematic review?

The available data is sufficient to determine that the CRP is a safe and effective short-term

treatment for posterior canal BPPV. Following one treatment session, the CRP successfully

resolves symptoms of vertigo and converts a positive to negative Dix-Hallpike test. In short-

term follow-up, individual trials and pooled data showed a statistically significant effect in favor

of the CRP over controls. The CRP is safe, with no serious complications. There is no good

evidence that the CRP provides a long-term resolution of symptoms. At the time of the search,

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there was no good evidence comparing the CRP with other physical, medical or surgical therapy

for posterior canal BPPV. Future updates of the review need to take into account subsequent

evidence comparing the CRP with other physical therapy treatments for posterior canal BPPV,

examining the effect size stratified by symptom duration, and comparing long-term follow-up of

symptom resolution between the CRP and other physical therapy treatments.

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Acknowledgments

Special thanks to Janet Callahan, PT, DPT, MS, NCS, Sarah Hourihan, PT, DPT, Rene Crumley,
PT, DPT, NCS, CEEAA, and Tammie Ostrowski, PT, for assisting with acquisition of digital
recordings of nystagmus. Special thanks to Eric Sanderson, PT, DPT, for illustrating Figure 3
(prediction of canalith repositioning procedure success and failure).

DOI: 10.2522/ptj.20130239

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Table 1.
Effectiveness of the CRP in the Treatment of PC-BPPV: Cochrane Review Results22

Study Characteristics
• 5 small RCTs were included (Search date May 19, 2010).
• Participants were 292 adults (>16 years old) with a clinical diagnosis of posterior canal BPPV
based on history and a positive Dix-Hallpike test. All studies included subjects with unilateral
posterior canal BPPV. One study also included subjects with bilateral posterior canal BPPV
and atypical BPPV. The duration of subjects’ symptoms varied.
• Intervention was modified CRP (no mastoid vibration). Comparator was sham maneuver in 4
trials or control in 1 trial.
• Follow-up ranged from immediately to 1 month post-treatment
Interventions
• Type of particle repositioning maneuver: CRP, sham maneuver (lying on affected side for 5
minutes, lying in the 1st lateral position of the liberatory maneuver for 5 minutes, and CRP
performed as if opposite ear affected), and control (untreated).
• Number of cycles per treatment session: Ranged from 1-5.
• Post-intervention postural and activity restrictions: Two trials instructed subjects in post-
intervention restrictions. Three trials had no post-intervention restrictions.
Outcomes
• Proportion of subjects who had complete resolution of their symptoms and who converted from
a positive to a negative Dix-Hallpike test.
• Two studies asked participants to complete a diary of symptoms.
Froehling et Lynn et al, Munoz et al, von Brevern Yimtae et al,
al, 200024 199525 200723 et al, 200621 200326
Measure CRP Sham CRP Sham CRP Sham CRP Sham CRP Contro
l
No. of 24 26 18 15 38 41 35 31 29 27
participants/
group
No. of 12(50 5(19) 11(61 3(20) 12(32 10(24 28(80 4(13) 12(41 1(4)
participants/ ) ) ) ) ) )
group with
complete
resolution of
symptoms (%)
No. of 16(67 10(38 16(89 4(27) 13(34 6(15) 28(80 3(10) 22(76 13(48)
participants/ ) ) ) ) ) )
group with
negative Dix-
Hallpike test
result (%)

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No. of 1 0 8 1 2 0
participants/
group with
complications
nausea/
vomiting/
fainting
Overall Low Low Low Low Insufficient data
assessment of to determine
risk of bias bias
Lost to follow- Completed data available for 273/292 patients.
up
Results
Complete Symptom outcome reported as dichotomous variable. Success defined as complete
resolution of resolution of symptoms or not. In each trial, a statistically significant difference in
symptoms symptom resolution in favor of the treatment group was observed. Pooled trail data
yielded an odds ratio of 4.42 (95% CI 2.62 to 7.44) in favor of treatment.
Negative Dix- In all trials, there was a statistically significant difference in conversion from a
Hallpike test positive to a negative Dix-Hallpike test in favor of the treatment group. Pooled trial
result data yielded an odds ratio of 6.40 (95% CI 3.63 to 11.28) in favor of treatment.
Safety No serious complications of treatment. Reported problems were inability to tolerate
treatment due to cervical spine problems, emesis during treatment, nausea, and
fainting.
Limitations
• None of the trials assessed outcome after 1 month so long term efficacy is unknown.
• At the time of the updated search there were no trials comparing CRP to other active
treatments.

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Table 2.
Pre-intervention and Post-intervention Outcome Measures

Outcome Measure Properties of Measure Pre Post

Activities-specific Range: 0-100 points 80 100
Balance Confidence Higher score indicates greater balance confidence.
(ABC) Scale28 Strong test-retest and high internal consistency in
community-dwelling older adults28 and valid in
individuals with complaints of dizziness37.
Dizziness Handicap Range: 0-100 points 84 0
Inventory27 Higher score indicates greater self-perceived
handicapping effects imposed by vestibular system
disease.
Dynamic Gait Index29 Range: 0-24 points 15 24
<19 increased risk of falling in community dwelling
older adults38 and patients with vestibular disorders.39
Inter-rater reliability of the DGI in patients with
vestibular disorders moderate.40
Timed “Up & Go” Asymptomatic healthy adults in 4th decade of life: Mean 9s 5s
Test30 time to complete 4.6 + 1.0 s, range 3.3 to 6.6 s.41

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Figure 1. Mechanisms of BPPV illustrated for left PC-BPPV. The cristae ampullaris of the fluid

filled semicircular canals contains sensory epithelium consisting of hair cells embedded within

the cupula, a fine, diaphragmatic membrane. Rotation of the head deflects the hair cells. The

utricular macula consists of a weighted sensory membrane, hair cells implanted within an

otolithic membrane weighted with calcite particles, otoconia. Gravitational forces on the head

deflect the hair cells.

© 2007, American Dizziness and Balance. Reprinted with permission.

Figure 2. Particle repositioning maneuvers. (A) Canalith repositioning procedure illustrated

for treatment of the right PC. The clinician moves the patient through a series of 4 positions,

starting with the placement of the involved canal in the head-hanging position of the Dix-

Hallpike Test. To begin, the patient is positioned in long sitting (sitting on the treatment table

with the legs extended). The patient's head is rotated 45 degrees towards the right. The patient

is then lowered into supine with the neck extended 30 degrees over the edge of the treatment

table. This is the head-hanging position. The head is rotated through 90° of motion ending in 45°

of neck rotation towards the uninvolved side, followed by rolling onto the uninvolved side while

maintaining the head on trunk position, and finally sitting up from lying on the uninvolved side.

Each position is maintained for a minimum of 45 seconds or as long as the nystagmus lasts plus

an additional 20 s. The procedure is repeated three times. (B) The liberatory (Semont)

maneuver illustrated for treatment of the right PC. The patient sits on the edge of the treatment

table. The clinician rapidly moves the patient to lying on the involved side with the head rotated

45° towards the uninvolved side. While maintaining the head on trunk position, the clinician

swings the patient from lying on the involved side to lying onto the uninvolved side. The head is

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then gently tapped on the treatment table. Each position is maintained for 1.5 minutes. The

procedure is repeated three times.

© 2007, American Dizziness and Balance. Reprinted with permission.

Figure 3. Movement of debris within the right PC during the canalith repositioning procedure

illustrated for treatment of the right PC. Arrow indicates direction of angular velocity and flow

of endolymph. Cupula acts as a plunger (diaphragm within ampulla). (A) Prediction of

successful outcome. With each position of the head, debris settles away from the cupula, creating

an ampullofugal flow of endolymph away from the cupula, exciting the hair cells within the

cristae ampullaris, and generating the same direction of nystagmus. (B) Prediction of failed

outcome. During the 2nd and/or 3rd position, the debris settles towards the cupula, reversing the

direction of flow of the endolymph towards the ampulla (ampullopetal), inhibiting the hair cells

within the cristae ampullaris, and reversing the direction of the nystagmus.

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 ANTERIOR SEMICIRCULAR CANAL

DIRECTION OF VIEW COMMON CRUS

STRAIGHT LATERAL POSTERIOR
SEMICIRCULAR CANAL

HORIZONTAL
SEMICIRCULAR CANAL
VESTIBULE
UTRICLE
SACCULE AMPULLA
CUPULA
COCHLEA
CRISTA AMPULLARIS
DISPLACED OTOCONIA
OTOCONIA
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
 Same Direction of Ny.
A

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 Effectiveness of the Canalith Repositioning
Procedure in the Treatment of Benign Paroxysmal
Positional Vertigo
Janet O. Helminski
PHYS THER. Published online June 5, 2014
doi: 10.2522/ptj.20130239

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