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TREATMENT
Posterior Semicircular Canal BPPV
Brandt–Daroff Exercise
Thomas Brandt and Robert Daroff (Brandt & Daroff,
1980) were the first to describe a treatment for BPPV.
The treatment, now commonly called the Brandt–Daroff
exercise, is a series of position changes carried out by
the patient, multiple times during the day. To perform
this exercise, the patient sits on the edge of a bed, rotates
the neck 45 degrees away from the affected ear, and
then, with eyes closed, lies down on the affected side
(Figures 11–4A and B). The patient remains in this position until the vertiginous symptoms stop. Then, keeping the neck rotated, the patient sits up. Once back in a
seated position, the patient rotates his/her head back to
neutral. After waiting 30 seconds — longer if needed for
any vertiginous symptoms to pass — the patient rotates
his/her neck 45 degrees toward the affected ear, and
then rapidly lies down on the unaffected side (Figures
11–4C and D). After 30 seconds, or longer if needed for
any vertiginous symptoms to pass, the patient sits back
up and rotates the neck back to neutral. In the original
study, this sequence of position changes was repeated
within one exercise session until the vertigo was not
provoked with the position changes. The patients performed the exercises every three hours while awake,
and the exercises were continued until they were free
of symptoms for two consecutive days. In current clinical practice, patients are commonly asked to perform
10 to 15 sequences in a row, three times a day. Brandt
and Daroff reported that 66 of the 67 patients had a
resolution of their signs and symptoms within 3 to 14
days. While the Brandt–Daroff exercise has often been
referred to as a habituation exercise, Brandt and Daroff
argued that the observed changes were too rapid for
habituation and were most likely due to a mechanical
displacement of the canaliths.
A B
Figure 11–4. The Brandt–Daroff exercise for left posterior SCC BPPV. A. Patient starts sitting on a bed with their
neck rotated 45 degrees to the right (to the unaffected side). B. Patient lies down quickly onto their left side (the
affected side), maintaining the neck rotation. Once the vertigo and nystagmus have stopped the patient sits up
still maintaining the neck rotation. They again wait until the vertigo and nystagmus have stopped, or 30 seconds if
they have no symptoms. continues
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While there was no control group in the study by
Brandt and Daroff, a more recent study (Amor-Dorado
et al., 2012) compared the Brandt–Daroff exercise (five
cycles per session, three sessions per day) to the canalith repositioning procedure (CRP). There was a statistically significant difference in the remission rate one
week after the treatment, with 80.5% of the patients
in the CRP group having negative Dix–Hallpike tests
compared with only 25% of the patients performing the
Brandt–Daroff exercises. This difference was present at
one month as well. Based on these studies, there is evidence that supports the use of the Brandt–Daroff exercise; however, other treatments may be more effective.
Particle Repositioning Maneuvers
The particle repositioning maneuvers (PRMs) are a
set of prescribed head movements and head positions
designed to move the canaliths through the involved
canal and into the utricular space. These movements
are often called the canalith repositioning procedure
(or canalith repositioning maneuver or treatment). The
term canalith repositioning procedure was used by Epley
(1992) to describe treatment of posterior SCC BPPV,
and we will reserve the use of CRP for that particular treatment and use PRM as a more general term. As
with testing for BPPV, the position of the head in space
is the critical factor during the PRMs. The treatments
described in the following sections may be modified
to accommodate patients and their physical limitations. For example, an individual with thoracic kyphosis and limited cervical extension may not be able to
extend his/her neck sufficiently during the CRP. The
treatment can be modified by placing the patient on a
tilt table with the head of the bed lower than the foot.
This positioning will allow the patient’s head to tilt
beyond horizontal, the critical position of the head,
while accommodating the patient’s kyphotic posture
and limited cervical range of motion.
Canalith Repositioning Procedure. Dr. John Epley
(1992) described the canalith repositioning procedure
C D
figure 11–4. continued C. Patient rotates the neck 45 degrees to the left. D. Patient lies down quickly onto their
right side, maintaining the neck rotation. They again wait until the vertigo and nystagmus have stopped, or 30seconds if they have no symptoms, and then they sit up. This sequence is repeated 10 to 15 times in a row, or until the
patient is asymptomatic with the position changes.
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for treatment of posterior SCC canalithiasis. The treatment was based on the hypothesis that the displaced
otoconia, the canaliths, were freely mobile in the semicircular canal and that one could use gravity and a
series of head positions to pull the canaliths away from
the ampulla and into the utricular space. To perform
the treatment, the patient starts sitting lengthwise on
a treatment table, with the neck rotated 45 degrees to
the affected side (Figure 11–5A). The clinician, maintaining the cervical rotation, then assists and guides the
patient into a supine position with the neck extended
30 degrees off the edge of the treatment table, essentially repeating the Dix–Hallpike test (Figure 11–5B).
The patient is kept in this position until the nystagmus stops. The clinician will guide the patient’s head
as the patient rotates the neck so that it is 45 degrees
to the other side (Figure 11–5C). The patient is again
kept in this position until the nystagmus stops. If no
nystagmus is observed with the change in head position, then the patient maintains this position for a time
equal to the duration of the nystagmus observed in
the Dix–Hallpike test. The patient will then roll onto the
unaffected side (Figure 11–5D). During this movement,
the 45 degrees of cervical rotation is maintained, and
as the patient rolls onto the side, the neck is brought
out of extension and into lateral flexion, side bending,
toward the treatment table. The patient will end up in
a side-lying position with the chin tucked down near
the undermost shoulder. Care should be taken during
this position change to avoid bringing the patient’s
head above horizontal. The side-lying position is again
maintained until the nystagmus stops, or if no nystagmus is observed, the patient maintains this position for
a time equal to the duration of the nystagmus observed
in the Dix–Hallpike test. Maintaining the head position
relative to the body, the clinician will assist the patient
back to sitting, at which point the patient can rotate the
neck back to neutral and come out of the flexed position (Figure 11–5E). Since the patient can develop nystagmus and vertigo once sitting upright, the clinician
should hold on to the patient and observe the patient’s
eyes upon completion of the treatment.
Clinicians have modified some aspects of the original CRP. Epley (1992) recommended the use of medications (transdermal scopolamine or diazepam) to reduce
nausea and prevent vomiting during the test and
treatment. There is no mention of the use of medication for these symptoms in the current clinical practice
guidelines (Bhattacharyya et al., 2017; Fife et al., 2008).
However, for patients with a history of vomiting with
BPPV, anti-emetic medications such as Phenergan® and
Compazine® may be useful. Epley also recommended
the use of mastoid vibration during treatment to help
move the canaliths through the canal. Studies to date
A B
figure 11–5. The canalith repositioning procedure (CRP) for treating left-sided posterior (or anterior) SCC canalithiasis. A. The patient starts sitting lengthwise on the treatment table, with their neck rotated 45 degrees to the
affected side. B. The clinician assists and guides the patient into supine, extending the patients neck off the edge
of the treatment table approximately 30 degrees below horizontal. The patient stays in this position at least until the
nystagmus stops, if not 15 to 30 seconds longer. continues
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C D
figure 11–5. continued C. The clinician will then rotate
the patient’s neck 90 degrees, so the patient ends up
in 45 degrees rotation to the right, maintaining the neck
extension throughout the movement.
remain in this position until the nystagmus stops, or as
long as they remained in the previous position. D. The
clinician will then assist and guide the patient into right
side lying. The patient maintains the 45 degrees of neck
rotation, but as they roll to the side, the clinician will
guide the patient’s neck from extension to side bending to the right, bringing the patient’s chin towards their
right shoulder. The patient will remain in this position until
the nystagmus stops, or as long as they remained in the
first supine position. E. The clinician assists the patient
into a seated position, maintaining the cervical rotation
and side bending as the patient sits up. Once upright,
the patient’s neck can be brought to an upright and
straight ahead position.
E
The patient will
(Hain, Helminski, Reis, & Uddin, 2000; Ruckenstein
& Shepard, 2007) have shown that vibration does not
improve the efficacy of the treatment. In addition, a
Cochrane Review (Hunt, Zimmermann, & Hilton,
2012) concluded that there was no evidence that vibration added to the treatment outcomes. Lastly, Epley
recommended that patients avoid lying down for 48
hours after the treatment. Massoud and Ireland (1996),
as well as Nuti and colleagues (2000), demonstrated no
difference in outcomes between those who received the
posttreatment restrictions and those who did not. The
Cochrane Review (Hunt, 2012) and a recent meta-analysis (Cromwell et al., 2018) concluded that there was no
clinical benefit to the posttreatment restrictions.
Semont Maneuver. Another PRM was described by
Semont, Freyss, and Vitte (1988), which is often referred
to as the Semont maneuver, Liberatory maneuver, or
Brisk maneuver. In the original paper, they suggested
that this treatment would work for either canalithiasis
or cupulolithiasis by moving the particles through the
posterior SCC, or off of the cupula. To perform the treatment as originally described, the patient starts sitting
on a treatment table. The clinician assists and guides
the patient into a side-lying position on the affected
side, letting the neck bend to bring the head to the table.
If there is no nystagmus, then the clinician rotates the
patient’s neck 45 degrees, facing away from the table
(Figures 11–6A and B). The patient will remain in this
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A B
figure 11–6. The Semont maneuver for left-sided posterior SCC canalithiasis or cupulolithiasis. A. The patient starts
sitting on the treatment table with their neck rotated 45 degrees to the right, which places the affected posterior
SCC in the plane of the movement. The patient may want to cross their arms and grasp the clinician’s forearms for
extra support. B.
The neck can then side bend to the left, bringing the head down to the table. The patient remains in this position
for 1 to 2 minutes after the nystagmus has stopped.
The patient is brought rapidly into left side lying, maintaining the 45 degrees of cervical rotation.
continues
position for two or three minutes after the nystagmus
has stopped. Maintaining the 45 degrees of cervical
rotation, the patient is quickly moved into the opposite
side-lying position, with a sudden deceleration of the
head in the clinician’s hands (Figure 11–6C). If there is
no nystagmus, the clinician slowly rotates the patient’s
neck 90 degrees and then rapidly rotates it back down
to the original 45-degree nose-down position (Figures
11–6D and E) to induce the nystagmus and vertigo. The
patient remains in this position for at least five minutes
and is then slowly brought back to the seated position.
Others have modified the timing of the treatment such
that the patient remains in the initial side-lying position for two minutes and the final side-lying position
for three minutes (Levrat, van Melle, Monnier, & Maire,
2003) or four minutes in each position (Herdman, Tusa,
Zee, Proctor, & Mattox, 1993). Others (Cohen & Kimball, 2005) actually modified the movements such that
from the initial side-lying position, the patient’s neck
was rotated to a 45-degree nose-down position, rather
than moving into side lying on the opposite side.
Outcomes
There is strong evidence to support the use of PRMs
in the treatment of posterior SCC BPPV. There are
numerous randomized controlled trials (RCTs) demonstrating the effectiveness of CRP for the treatment
of posterior SCC BPPV (Cohen & Kimball, 2005; Froehling et al., 2000; Lynn, Pool, Rose, Brey, & Suman, 1995;
Simhadri, Panda, & Raghunathan, 2003; von Brevern
et al., 2006; Yimtae, Srirompotong, Srirompotong, &
Sae-Seaw, 2003). These studies reported success rates
of 41% to 95% in the treatment groups compared with
4% to 35% in the control groups. Some of the variability in these numbers is due to the timing of the posttreatment assessments, which ranged from 24 hours to
four weeks. In addition to the RCTs, there have been
Cochrane Reviews (Hilton & Pinder, 2004; Hunt et al.,
2012) and meta-analyses (White, Savvides, Cherian, &
Oas, 2005; Woodworth, Gillespie, & Lambert, 2004),
which all support the use of CRP. The two published
clinical practice guidelines (Bhattacharyya et al., 2017;
Fife et al., 2008) both recommend the use of CRP for
treatment of posterior SCC BPPV.
While there have not been as many investigations
of the Semont maneuver, numerous studies have demonstrated the effectiveness of this treatment approach.
Semont and colleagues (1988) reported an 84% success rate with one maneuver and a 93% success rate
with two maneuvers. Herdman and colleagues (1993)
reported a 70% success rate with one treatment; while
Levrat and colleagues (2003) reported a 63% success
rate after one treatment and an 84% success rate with
two treatments. In a controlled study, where the sham
treatment was the Semont maneuver to the unaffected
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C D
figure 11–6. continued C. The clinician, along with
assistance from the patient, rapidly moves the patient
from left side lying to right side lying, maintaining the
rightward neck rotation throughout the movement.
is a sudden deceleration of the patient’s head in the
clinician’s hands as the patient’s shoulder and the clinician’s forearm hit the treatment table.
experience vertigo at this point.
rotate the patient’s neck 90 degrees to the left (D) and
then rapidly back down towards the treatment table (E).
The original description of the treatment called for the
patient to remain in this position for 5 minutes after the
cessation of the vertigo and nystagmus. In clinical practice today, the patient typically remains in this position for
2 minutes after the vertigo and nystagmus stop. The clinician will then guide the patient back to a seated position, maintaining the cervical rotation until the patient is
upright.
E
the clinician standing behind the patient.
Note that this treatment may be performed with
The patient should
If not, the clinician can
There
side, Mandalà and colleagues (2012) reported an 87%
success rate in the treatment arm at 24 hours compared
with a 0% success rate in the sham arm. Published clinical practice guidelines (Bhattacharyya et al., 2017; Fife
et al., 2008) support the use of the Semont maneuver
for the treatment of posterior SCC BPPV, but due to
the paucity of studies comparing the Semont maneuver
with CRP, the practice guidelines did not make recommendations regarding the comparative effectiveness of
two PRMs.
Treatment Considerations
Since the posttreatment restrictions are not required,
clinicians may retest and repeat treatment as needed
within one treatment session. There is marked variabil-
ity in the literature in terms of the number of maneuvers performed in a treatment session, from one per
session (Lynn et al., 1995), to repeated maneuvers
(maximum of five) until there is resolution of the nystagmus in the Dix–Hallpike test (Froehling et al., 2000).
Due to this variability, the clinical practice guideline
(Bhattacharyya et al., 2017) makes no recommendations as to the number of maneuvers performed in a
treatment session. Based on the literature, repeat testing and treatment within a given session are not contraindicated. The clinician, however, should be mindful
of the patient’s overall symptoms as repeated provocation can lead to nausea and emesis.
Complications from PMRs are rare and mild. No
serious complications were reported in the RCTs. Mild
complications of nausea, vomiting, fainting, and canal
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conversions were present in 6% to 12% of the patients
(Herdman & Tusa, 1996; Yimtae et al., 2003). Herdman
and Tusa (1996) reported that of 85 patients treated
with CRP for posterior SCC BPPV, 6% presented with
a canal conversion on reassessment. Three individuals developed horizontal SCC BPPV, and 2 individuals
developed anterior SCC BPPV. Yimtae and colleagues
(2003) reported that 2 of 22 patients treated for posterior SCC BPPV with CRP developed canal conversions,
and in both cases it was the horizontal SCC that was
affected. Canal conversions are infrequent and, based
on the above studies, are more likely to occur in the
horizontal SCC. A modeling study of BPPV (Rajguru,
Ifediba, & Rabbitt, 2004) suggests that during CRP, as
the patient is lying on the side, the neck should be laterally flexed away from the table to decrease the conversion of posterior to anterior SCC BPPV. As canal
conversions to the anterior SCC are rare, and as this is
a modeling study with no clinical data to support it, the
recommended modification to CRP seems premature
at this time.
Anterior Semicircular Canal BPPV
There are numerous treatments that have been proposed for anterior SCC BPPV, but unfortunately all the
studies are purely descriptive in nature. Initially, the
“reverse Epley” maneuver was suggested as a treatment for anterior SSC canalithiasis (Epley, 2001; Honrubia, Baloh, Harris, & Jacobson, 1999); this maneuver
is simply CRP performed as if treating the contralateral
posterior SCC. The data supporting this treatment are
meager at best, with fewer than five patients in each of
the studies and unclear outcomes (Honrubia et al., 1999;
Korres, Riga, Balatsouras, & Sandris, 2008; Seok, Lee,
Yoo, & Lee, 2008). Also, from an anatomical perspective, this series of head positions would not appear to be
effective in clearing the particles from the anterior SCC.
We will describe here the three treatment approaches
that have moderate evidence to support their use.
Particle Repositioning Maneuvers
CRP, as described in the previous section for posterior
SCC BPPV, has been used successfully for the treatment of anterior SCC canalithiasis (Jackson, Morgan,
Fletcher, & Krueger, 2007; Lopez-Escamez, Molina, &
Gamiz, 2006). Lopez-Escamez and colleagues (2006)
reported that 11 of 14 individuals with anterior SCC
canalithiasis had resolution of their signs and symptoms after one CRP. Similarly, Jackson et al. (2007)
reported that 40 patients with anterior SCC canalithiasis required an average of 1.34 maneuvers to clear their
signs and symptoms of BPPV. Note that if, for example,
it is the right anterior SCC that is involved, the patients
starts the treatment with the neck rotated 45 degrees to
the right, just as if they were treating the right posterior
SCC BPPV. Korres and colleagues (2010) suggested that
CRP for the anterior SCC canalithiasis could be performed by bringing the patient to a seated position
after the first 90-degree rotation of the head away from
the affected side.
Kim and colleagues (2005) proposed a different
treatment for anterior SCC BPPV. For this treatment,
the patient starts by sitting on a treatment table and
rotates the neck 45 degrees to the unaffected side
(Figure 11–7A). Maintaining the cervical rotation, the
clinician will assist and guide the patient to a supine
position, with the neck extended 30 to 45 degrees off
the end of the table (Figure 11–7B); note that there is
this discrepancy in the original article about the degree
of neck extension. The patient remains in this position
for two minutes. The clinician then brings the patient’s
neck back to 0 degrees of extension (Figure 11–7C), and
the patient remains in this position for one minute.
The clinician will then assist and guide the patient to a
seated position, with the neck in 0 degrees of rotation
and 30 degrees of flexion (Figure 11–7D). In a study of
60 patients with anterior SCC canalithiasis, Kim and
colleagues (2005) found resolution of signs and symptoms in 46.7% following one treatment, and in 80%
after two treatments. Six patients required more than
two treatments, and 96.7% of the patients ultimately
had resolution of the signs and symptoms.
A different PRM was described by Yacovino, Hain,
and Gualtieri (2009). For this treatment, the patient
starts by sitting lengthwise on a treatment table with no
neck rotation (Figure 11–8A). The clinician will assist
and guide the patient to a supine position, with the
neck extended 30 degrees off the end of the table (Figure 11–8B). The patient remains in this position for 30
seconds. The clinician then quickly flexes the patient’s
neck to a chin-to-chest position (Figure 11–8C), and the
patient remains in this position for 30 seconds. The clinician will then assist and guide the patient to a seated
position, maintaining the neck in the flexed position
(Figure 11–8D). After 30 seconds in this position, the
patient can lift the chin off of the chest. In the initial
study of 13 individuals with anterior SCC canalithiasis,
Yacovino et al. (2009) found that 84.6% of the patients
had resolution of their signs and symptoms following
one treatment, and 100% had resolution of their signs
and symptoms after two treatments.
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A B
C D
figure 11–7. Treatment of left anterior SCC canalithiasis as described by Kim et al. (2005). A. The patient starts sit-
ting lengthwise on the treatment table, with their neck rotated 45 degrees to the right, which places the affected
anterior SCC in the sagittal plane. B. The clinician guides the patient into supine and extends the neck 45 degrees
below horizontal, maintaining the cervical rotation.
will then raise the patient’s head so that there is no neck extension. The patient stays in this position for 1 minute.
D.The clinician then assists the patient into sitting, and guides the patient’s neck into flexion (chin to chest) and
into neutral rotation. The patient remains in this position for 30 to 60 seconds.
The CRP and the procedures described by Kim
et al. (2005) and Yacovino et al. (2009) were all assessed
as a case series without a control group for comparison.
Without a control group or comparison studies, one
cannot determine if the treatments are truly effective,
nor can one make a recommendation for one of these
treatments over another.
Anterior SCC cupulolithiasis is a rare entity, and
is not often described in the literature. As such there is
The patient remains in this position for 2 minutes. C. The clinician
no evidence to support any given treatment. Jackson
and colleagues (2007) reported that in their sample of
55 patients with anterior SCC BPPV, 15 had cupulolithiasis based on the duration of the nystagmus elicited
in the Dix–Hallpike test. These patients were treated
with either CRP with applied mastoid vibration, or the
Semont maneuver followed by CRP. There was no indication in their study if either of these treatment regimens was beneficial.
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A B
C D
Figure 11–8. Treatment of anterior SCC canalithiasis as described by Yacovino et al. (2009). A. The patient starts
sitting lengthwise on the treatment table, with their neck in neutral. B.
and extends the neck 30 degrees below horizontal, with no cervical rotation. The patient remains in this position for
30 seconds. C. The clinician will then quickly flex the patient’s neck, bringing their chin to their chest. The patient
stays in this position for 30 seconds. D. The clinician then assists the patient into sitting, maintaining the neck flexion
for another 30 seconds.
Horizontal Semicircular Canal BPPV
with
Geotropic Nystagmus
As discussed previously, the finding of bilateral geotropic nystagmus during the positioning tests is consistent with horizontal SCC canalithiasis, with the
canaliths located in the posterior arm of the horizontal
SCC. There are several treatment procedures that have
been proposed for treatment of this condition: (1) the
particle repositioning maneuver incorporating a 270 to
The clinician guides the patient into supine
360-degree roll, (2) the Appiani maneuver, sometimes
referred to as the Gufoni maneuver, and (3) forced prolonged positioning. These treatments will be described
and supporting studies will be reviewed.
Particle Repositioning Maneuvers
Canalith Repositioning Procedure/Lempert Maneuver.
A modification of CRP for the posterior canal was
suggested to treat horizontal SCC canalithiasis (Lem-
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pert & Tiel-Wilck, 1996). The treatment consisted of
a series of rapid 90 degree rotations away from the
affected ear, with the patient starting in a supine position. The total rotation encompassed 270 degrees, so
the patient would end up lying on the affected side.
Others (Honrubia et al., 1999; Kim et al., 2012a; Tirelli
& Russolo, 2004) have performed the treatment starting with the patient supine with the neck rotated 90
degrees to the affected side, and then performed a
series of 90 degree rotations, completing the treatment
with the patient either prone (270 degree rotation) or
side-lying on the affected side (360 degree rotation). In
theory, starting the treatment with the patient supine
and the neck rotated to the affected side would allow
canaliths in the anterior aspect of the horizontal SCC to
migrate to a more posterolateral position in the canal.
There have been no studies comparing the efficacy of
the two ending positions (prone or side lying), so that
decision will rest with the clinician based in part on
the mobility and physical capabilities of the patient. To
perform the treatment the patient starts lying supine
with the neck rotated 90 degrees to the affected ear
(Figure 11–9A). The patient will remain in this position
for 30 to 60 seconds until the nystagmus stops. Note
that a patient with limited cervical rotation will simply start in side lying on the affected side. From this
initial position, the clinician will guide the patient in
rotating the neck 90 degrees away from the affected
ear, incorporating 20 to 30 degrees of neck flexion to
place the horizontal SCC in an earth vertical orientation (Figure 11–9B). Again, the patient will remain in
this position for 30 to 60 seconds until the nystagmus
stops. From this position, the patient will rotate the
neck another 90 degrees to the right. Given the subsequent position changes, it is often easier to simply
have the patient rotate the entire body 90 degrees to
lie on the unaffected side, without the cervical rotation (Figure 11–9C). Again, the patient will remain in
A B
figure 11–9. The CRP, or Lempert maneuver, for left-sided, horizontal SCC canalithiasis. A. Patient starts in supine
with their neck rotated 90 degrees to the left. The clinician will support the patient’s head. The patient remains in
this position for 30 to 60 seconds, or until the nystagmus stops. B. The clinician guides the patient’s head to neutral
rotation, and holds the head in 30 degrees of flexion to place the horizontal SCC in an earth vertical orientation.
The patient remains in this position for 30 to 60 seconds, or until the nystagmus stops. continues
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