2006 American Academy of Neurology

Practice Parameter: Therapies

for benign paroxysmal
positional vertigo (an
evidence-based review)
Report of the Quality Standards
Subcommittee of the American Academy
of Neurology
T.D. Fife, MD; D.J. Iverson, MD; T. Lempert, MD; J.M. Furman,
MD, PhD; R.W. Baloh, MD; R.J. Tusa, MD, PhD; T.C. Hain, MD;
S. Herdman, PT, PhD, FAPTA; M.J. Morrow, MD; G.S. Gronseth,
MD

2006 American Academy of Neurology
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2006 American Academy of Neurology
Presentation Objectives

To perform an evidence-based review of
the treatment of benign paroxysmal
positional vertigo
To make evidence-based
recommendations
2006 American Academy of Neurology
Overview

Background
Gaps in care
AAN guideline process
Analysis of evidence, conclusions,
recommendations
Recommendations for future research
2006 American Academy of Neurology
Background

BPPV is a clinical syndrome characterized
by brief recurrent episodes of vertigo
triggered by changes in head position with
respect to gravity.
BPPV is the most common cause of
recurrent vertigo, with a lifetime
prevalence of 2.4%.
1

The duration, frequency, and intensity of
symptoms of BPPV vary, and spontaneous
recovery occurs frequently.
2006 American Academy of Neurology
Inner ear

2008, Barrow
2006 American Academy of Neurology
BPPV by canal type

Posterior Horizontal Anterior
Estimated frequency
2-6
81-89% 8-17% 1-3%
Provocative maneuver Dix Hallpike* Supine Roll Test (Pagnini-McClure) Dix Hallpike*
Nystagmus Upbeat, torsional Horizontal
Direction Changing
Downbeat**, torsional
* In posterior canal benign positional vertigo, nystagmus is provoked
following Dix Hallpike positioning with the affected ear down. In
anterior canal benign positional vertigo, nystagmus is provoked
following Dix Hallpike positioning with the affected ear up.
** The observation of downbeating positional nystagmus requires
careful assessment to rule out brainstem or cerebellar lesions.
2006 American Academy of Neurology
Gaps in Care

There are a number of repositioning
maneuvers in use, but they lack
standardization.
Several video clips and figure drawings
are available at www.aan.com but do not
include all variations for treatment.
2006 American Academy of Neurology
AAN Guideline Process

Clinical Question

Evidence

Conclusions

Recommendations

2006 American Academy of Neurology
Clinical Questions

First step of developing guidelines is to
clearly formulate questions to be answered.
Questions address areas of controversy,
confusion, or variation in practice.
Questions must be answerable with data
from the literature.
Answering the question must have the
potential to improve care/patient outcomes.
2006 American Academy of Neurology

Literature Search/Review:
Relevant
Complete
Search
Review abstracts
Review full text
Select articles
Rigorous, Comprehensive, Transparent
2006 American Academy of Neurology
AAN Classification of
Evidence

All studies rated Class I, II, III, or IV
Five different classification systems:
Therapeutic
Randomization, control, blinding
Diagnostic
Comparison to gold standard
Prognostic
Screening
Causation

2006 American Academy of Neurology

AAN Level of
Recommendations
A = Established as effective, ineffective, or harmful for
the given condition in the specified population.
B = Probably effective, ineffective, or harmful for the
given condition in the specified population.
C = Possibly effective, ineffective, or harmful for the
given condition in the specified population.
U = Data is inadequate or conflicting; given current
knowledge, treatment is unproven.

Note that recommendations can be positive or negative.

2006 American Academy of Neurology
Translating Class to
Recommendations
A = Requires two consistent Class I
studies.
B = Requires one Class I study or two
consistent Class II studies.
C = Requires one Class II study or two
consistent Class III studies.
U = Studies not meeting criteria for
Class I through Class III.

2006 American Academy of Neurology
Applying This Process
to the Issue



We will now turn our attention to the
guidelines.
2006 American Academy of Neurology
Clinical Questions
1. What maneuvers effectively treat posterior canal
BPPV?
2. Which maneuvers are effective for anterior and
horizontal canal BPPV?
3. Are postmaneuver restrictions necessary?
4. Is concurrent mastoid vibration important for efficacy of
the maneuvers?
5. What is the efficacy of habituation exercises, Brandt-
Daroff exercises, or patient self-administered treatment
maneuvers?
6. Are medications effective for BPPV?
7. Is surgical occlusion of the posterior canal or singular
neurectomy effective for BPPV?
2006 American Academy of Neurology
Methods
Medline, EMBASE and Current Contents:
1966 to June 2006
Relevant, fully published, peer-reviewed articles
Supplemented through manual searches by panel
members
Search terms:
Benign paroxysmal positional vertigo, Semont
liberatory maneuver, canalith repositioning maneuver,
particle repositioning maneuver, Epley maneuver,
modified Epley maneuver
2006 American Academy of Neurology
Methods
Panel comprised of otoneurologists with
expertise in BPPV and general neurologists with
methodologic expertise.
At least two panelists reviewed each article for
inclusion.
Risk of bias determined using the classification
of evidence for each study (Class IIV).
Strength of practice recommendations linked
directly to level of evidence (Level AU).
Conflicts of interests disclosed.
2006 American Academy of Neurology
Literature Review
70 articles
399 abstracts
Inclusion criteria:
- Relevant to the
clinical questions
- Limited to human
subjects
-RCT, case control,
cohort studies, case
series > 6, meta-
analysis

Exclusion criteria:
-Abstracts, reviews,
and undocumented or
unstated mention of
improvement

2006 American Academy of Neurology
AAN Classification of Evidence
for Therapeutic Intervention
Class I: Randomized, controlled clinical trial with masked
or objective outcome assessment in a representative
population. Relevant baseline characteristics are
presented and substantially equivalent among treatment
groups or there is appropriate statistical adjustment for
differences. The following are required:
a) concealed allocation
b) primary outcome(s) clearly defined
c) exclusion/inclusion criteria clearly defined, and
d) adequate accounting for drop-outs (with at least 80%
of enrolled subjects completing the study) and cross-
overs with numbers sufficiently low to have minimal
potential for bias.

2006 American Academy of Neurology
Class II: Prospective matched group
cohort study in a representative population
with masked outcome assessment that
meets b-d above OR a randomized
controlled trial in a representative
population that lacks one criteria a-d.
AAN Classification of Evidence
for Therapeutic Intervention
2006 American Academy of Neurology
Class III: All other controlled trials (including well-defined
natural history controls or patients serving as own
controls) in a representative population, where outcome
is independently assessed, or independently derived by
objective outcome measurement*.

Class IV: Studies not meeting Class I, II, or III criteria
including consensus, expert opinion, or a case report.

*Objective outcome measurement: an outcome measure
that is unlikely to be affected by an observers (patient,
treating physician, investigator) expectation or bias (e.g.,
blood tests, administrative outcome data).

AAN Classification of Evidence
for Therapeutic Intervention
2006 American Academy of Neurology
Analysis of Evidence
Question 1: What maneuvers
effectively treat posterior canal
BPPV?
Canalith repositioning procedure (CRP)
15 RCTs identified (two Class I
2,3
and three
Class II
4-6
studies).
Semont maneuver
4 studies identified (one class II
6
, one Class III
7

two Class IV
8,9
studies).

2006 American Academy of Neurology
Analysis of Evidence (CRP)
36 patients
2
compared CRP to sham in
supine position with affected ear down for
5 minutes and then sat up.
All patients symptomatic for at least 2
months/ median duration of symptoms
was 17 months (range 2-240 months) in
treatment group and 4 months (range 2-
276 months) in control group.
2006 American Academy of Neurology
Analysis of Evidence (CRP)
At 4 weeks, 61% of treated group reported
complete resolution vs. 20% of sham-
treated group (p=0.032). NNT = 2.44.
Dix-Hallpike maneuver was negative in
88.9% of treated patients vs. 26.7% in
sham-treated patients (p<0.001, NNT =
1.60) as measured by an observer blinded
to treatment.
2006 American Academy of Neurology
Canalith Repositioning
Procedure
2008, Barrow
2006 American Academy of Neurology
Analysis of Evidence (CRP)
Randomized controlled trial and crossover study
3

66 patients with a diagnosis of posterior BPPV based on a
positive Dix-Hallpike maneuver, compared a CRP with
sham.
After 24 hours, 80% of treated patients were asymptomatic
and had no nystagmus compared with 10% of sham
patients (p<0.001, NNT = 1.43).
Ninety-three percent of patients from original control
reported resolution of symptoms 24 hours after undergoing
CRP.
By 1 week, 94% of patients in the original treatment group
and 92% of patients in original control were asymptomatic.
At 4 weeks, 85% of patients in both groups were
asymptomatic.
2006 American Academy of Neurology
Analysis of Evidence (CRP)
Three studies were rated as Class II
4-6
because the method of
allocation concealment* was not specified.

Remaining RCTs were graded Class IV because they did not clearly
state whether the outcomes were obtained in a blinded and
independent manner
10-17
or because of important baseline difference
between study and control groups.
18

Five additional studies were identified (four meta-analyses
19-22
and
one systematic review). All references in the meta-analyses were
reviewed individually for this practice parameter.

*Technique for preventing researchers from inadvertently influencing which patients are
assigned to the treatment or placebo group (may cause selection bias that overestimates
the treatment effect).
23
2006 American Academy of Neurology
Analysis of Evidence
One study
6
showed patients treated with Semont
maneuver were significantly improved
compared to those treated with sham.
One study randomized 156 patients to Semont
maneuver, medical therapy and no treatment.
Six month follow-up, 94.2% of patients treated with
Semont maneuver reported symptom resolution, vs.
57.7% of patients treated medically and 34.6% of
patients who received no treatment.
Semont Maneuver
2006 American Academy of Neurology
Semont maneuver
2008, Barrow
2006 American Academy of Neurology
Analysis of Evidence

One Class IV study
8
comparing Semont
and a CRP with or without post-treatment
found success rates for all groups ranging
from 88% to 96%, with no difference
between groups.
Semont Maneuver
2006 American Academy of Neurology
Analysis of Evidence
Another Class IV study
9
compared patients
randomized to treatment with CRP, Semont
maneuver, or Brandt-Daroff exercises.
Symptom resolution among those treated with either
CRP or Semont maneuver at 1 week was the same
(74% vs 71%; 24% for Brandt-Daroff exercises).
At 3-month follow-up, 93% of patients treated with
CRP were asymptomatic vs. 77% of those treated
with Semont maneuver (p=0.027); 62% of patients
treated with Brandt-Daroff exercises were
asymptomatic at 3 months.
Semont Maneuver
2006 American Academy of Neurology
Conclusions
Two Class I studies and three Class II studies
have demonstrated a short-term (1 day to 4
weeks) resolution of symptoms in patients
treated with the CRP (NNT ranging from 1.43 to
3.7).
The Semont maneuver is possibly more effective
than no treatment (Class III), a sham treatment
(Class II), or Brandt-Daroff exercises (Class IV)
as treatment for posterior canal BPPV.
Two Class IV studies comparing CRP with
Semont maneuver have produced conflicting
results.
2006 American Academy of Neurology
Recommendations
CRP is established as an effective and safe
therapy that should be offered to patients of all
ages with posterior semicircular canal BPPV
(Level A).
The Semont maneuver is possibly effective for
BPPV (Level C).*
There is insufficient evidence to establish the
relative efficacy of the Semont maneuver to CRP
(Level U).

* Single Class II study.
2006 American Academy of Neurology
Analysis of Evidence
Question 2: Which maneuvers are the
most effective treatments for
horizontal canal and anterior canal
BPPV?
Horizontal canal BPPV
21 studies identified
24-44
(Class IV).
Anterior canal BPPV
2 studies identified
45,46
(Class IV).

2006 American Academy of Neurology
Analysis of Evidence
Horizontal canal BPPV accounts for 10-
17% of BPPV,
24-28
though some reports
have been even higher.
29,30

The nystagmus and vertigo of horizontal
canal BPPV may be provoked by the Dix-
Hallpike maneuver but are more reliably
induced by the supine head roll test
(Pagnini-McClure maneuver).
33-35

Horizontal Canal BPPV
2006 American Academy of Neurology
Analysis of Evidence
CRP or modified Epley maneuvers are
usually ineffective for horizontal canal
BPPV,
7-9,24-33,47
so a number of alternative
maneuvers have been devised.
Modified maneuvers include the Lempert
maneuver (barbecue roll), the Gufoni
maneuver, and the Vanucchi-Asprella
liberatory maneuver. Success in treatment for
each of these maneuvers is based on Class
IV data.

Horizontal Canal BPPV
2006 American Academy of Neurology
Supine roll test
(Pagnini-McClure maneuver)
2008, Barrow
2006 American Academy of Neurology
Lempert roll maneuver
2008, Barrow
2006 American Academy of Neurology
Analysis of Evidence
Anterior Canal BPPV
Anterior canal BPPV is usually transitory and
most often the result of canal switch that
occurs in the course of treatment more common
forms of BPPV.
47

Success rates were between 92-97%,
45, 46

though there were no controls to determine
whether this represents an improvement over
the natural history of this frequently self-
resolving form of BPPV.

2006 American Academy of Neurology
Conclusions/Recommendation

Based on Class IV studies, variations of the
Lempert supine roll maneuver, the Gufoni
method, or forced prolonged positioning seem
moderately effective for horizontal canal BPPV.
Two uncontrolled Class IV studies report high
response rates to maneuvers for anterior canal
BPPV.
No recommendation can be made (Level U).
2006 American Academy of Neurology
Analysis of Evidence
Question 3: Are postmaneuver activity
activity restrictions necessary after
canalith repositioning treatment?

One Class I
2
, one Class II
4
and six Class
IV studies.
8,48-52

2006 American Academy of Neurology
Analysis of Evidence
One Class I study
2
and one Class II study
4

demonstrating the benefit of CRP, patients wore
a cervical collar for 48 hours and avoided
sleeping on the affected side for 1 week.
Five Class IV studies
8,48-52
comparing CRP with
and without post-treatment activity restriction
showed no added benefit from post-treatment
activity restriction or positions.
One Class IV study
52
showed minimal benefit in
patients with post-activity restrictions.
2006 American Academy of Neurology
Conclusion/Recommendation

Based on six Class IV studies, there is
insufficient evidence to determine the
efficacy of post-maneuver restrictions in
patients treated with CRP.
No recommendation can be made
(Level U).
2006 American Academy of Neurology
Analysis of Evidence
Question 4: Is it necessary to include
mastoid vibration with repositioning
maneuvers?

One Class II,
53
one Class III
54
and three
Class IV studies.
11,55,56

2006 American Academy of Neurology
Analysis of Evidence
One Class II study
53
comparing patients with
posterior canal BPPV treated by appropriate
canalith repositioning maneuvers, performed
with and without vibration, showed no
difference in immediate symptom resolution or
relapse rate between groups.
One Class III study
54
compared patients
treated by CRP with and without mastoid
vibration. There was no difference in symptom
relief between the groups at 4 to 6 weeks
(p=0.68).
2006 American Academy of Neurology
Analysis of Evidence
Two Class IV studies
55,56
showed no
difference in the rate of symptom
resolution between patients treated by a
CRP with or without mastoid vibration.
A third Class IV study
11
reported that of
patients treated by a CRP with vibration,
92% were improved, vs. 60%
improvement with CRP alone.
2006 American Academy of Neurology
Conclusion
One Class II, one Class III, and two Class
IV studies showed no added benefit when
mastoid vibration was added to a CRP as
treatment for posterior canal BPPV.
2006 American Academy of Neurology
Recommendation
Mastoid oscillation is probably of no added
benefit to patients treated with CRP for
posterior canal BPPV (Level C).
2006 American Academy of Neurology
Analysis of Evidence
Question 5: What is the efficacy of
Brandt-Daroff exercises, habituation
exercises, or patient self-administered
treatments for BPPV?

One Class II
6
and one Class IV study.
9

2006 American Academy of Neurology
Analysis of Evidence
One Class II study
6
randomized patients to a
CRP, a liberatory maneuver, Brandt-Daroff
exercises, habituation exercises, or sham
treatment found that patients treated with
habituation exercises did no better than those
treated with sham. Patients treated with Brandt-
Daroff exercises did worse than those treated
with CRP or liberatory maneuvers, but were not
compared with sham treated patients.
2006 American Academy of Neurology
Analysis of Evidence
One Class IV study
9
compared Brandt-Daroff
exercises, performed three times daily, with the
Semont maneuver or CRP.
Patients treated with maneuvers were pretreated with
diazepam and given postmaneuver activity
restrictions; patients treated with Brandt-Daroff
exercises were not. Compliance was not recorded.
At 1-week follow-up, 24% of patients treated with
Brandt-Daroff exercises were symptom free, vs. 74%
of those treated with the Semont maneuver or CRP.
2006 American Academy of Neurology
Conclusion
One Class II and one Class IV study
suggest that BrandtDaroff exercises or
habituation exercises are less effective
than CRP in the treatment of posterior
canal BPPV.

2006 American Academy of Neurology
Recommendations
Self-administered BrandtDaroff exercises
or habituation exercises are less effective
than CRP in the treatment of posterior
canal BPPV (Level C).

There is insufficient evidence to
recommend or refute self-treatment using
Semont maneuver or CRP for BPPV
(Level U).

2006 American Academy of Neurology
Analysis of Evidence
Question 6: What is the efficacy of
medication treatments for BPPV?

Two Class III studies.
47,57
2006 American Academy of Neurology
Analysis of Evidence
One Class III study
57
found no difference
between lorazepam, 1mg three times daily;
diazepam, 5mg three times daily; or placebo
over the 4-week study period.
One Class III study
47
found that flunarizine was
more effective than no treatment but less
effective than Semont maneuver in eliminating
symptoms.
There are no randomized controlled trials of
meclizine or other drugs used for motion
sickness in the treatment of BPPV.
2006 American Academy of Neurology
Conclusions/Recommendation

A single Class III study did not demonstrate that
lorazepam or diazepam hastened resolution of
symptoms in BPPV.
Another Class III study demonstrated some
benefit of flunarizine (unavailable in the US) in
BPPV.
There is no evidence to support or refute a
recommendation of any medication in the
routine treatment for BPPV (Level U).
2006 American Academy of Neurology
Analysis of Evidence
Question 7: What are the safety and
efficacy of surgical treatments for
posterior canal BPPV?

Six Class IV studies.
58-63

2006 American Academy of Neurology
Analysis of Evidence
Five Class IV studies
58-62
with a total of 86
patients undergoing canal occlusion, reported
complete relief of BPPV symptoms in 85, as
ascertained by the treating surgeon.
Reported complications included a mild conductive
hearing loss for 4 weeks or less, mild and transient
unsteadiness in most patients, and a high frequency
sensorineural hearing loss in 6 patients.
One Class IV study
63
of singular neurectomy as
a treatment for intractable BPPV, 96.8% were
reported to have complete relief.
Severe sensorineural hearing loss occurred in 3.7%
of patients.
2006 American Academy of Neurology
Conclusion/Recommendation

Six unblinded, retrospective Class IV studies
report relief from symptoms of BPPV in nearly
every patient undergoing posterior semicircular
canal occlusion or singular neurectomy.
The studies do not provide sufficient
evidence to recommend or refute posterior
semicircular canal occlusion or singular
neurectomy as treatment for BPPV (Level U).
2006 American Academy of Neurology
Future Research
Class I studies are needed to clarify the
best treatments for horizontal canal BPPV.
Future studies on these topics should
adhere to the Consolidated Standards of
Reporting Trials (CONSORT) criteria using
validated, clinically relevant outcomes.
2006 American Academy of Neurology
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2006 American Academy of Neurology
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2006 American Academy of Neurology
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2006 American Academy of Neurology
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2006 American Academy of Neurology
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2006 American Academy of Neurology
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2006 American Academy of Neurology
References (cont.)
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2006 American Academy of Neurology
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2006 American Academy of Neurology
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Published in Neurology May 27, 2008 70:2067-2074
2006 American Academy of Neurology
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