The Semont maneuver for right-sided BPPV. (1 ) Patient is seated in the upright position; then the patient’s head is turned 45 degrees toward the left side, and the patient is then rapidly moved to the side-lying position as depicted in position (2). This position is held for approximately 30 seconds, and then the patient is rapidly moved to the opposite side-lying position without pausing in the sitting position and without changing the head position relative to the shoulder, resulting in position (3). This position is maintained for 30 seconds and then the patient gradually resumes the upright sitting position. (Adapted from reference 19.) 

Context in source publication

Context 1

... recent Cochrane collab- orative review of the Epley maneuver for BPPV. 42,59,128,129 The Cochrane review identified a statistically significant effect in favor of the CRP compared with controls. An odds ratio of 4.2 (95% confidence interval, 2.0-9.1) was found in favor of treatment for subjective symptom resolution in posterior canal BPPV; an odds ratio of 5.1 (95% confidence interval, 2.3-11.4) was found in favor of treatment for conversion of a positive to negative Dix-Hallpike test. Subsequently, additional RCTs have been published regarding the CRP, reflecting similar results. Table 7 summa- rizes recent RCTs evaluating CRP for posterior canal BPPV. Of note, consistent with the expected spontaneous resolution of posterior canal BPPV over time, treatment effects between CRP and control patients tended to diminish over time. In the short term, typically at 1 week, the CRP is very effective at providing symptom resolution for posterior canal BPPV with small numbers needed to treat (NNT). All but one of the RCTs for CRP has taken place in the specialized clinic setting, most commonly with a referred population, which may limit the generalizability of these results. In the only RCT conducted in the primary care setting, investigators were unable to demonstrate a significant benefit for the CRP based on symptomatic outcome. 130 At 1 week follow-up, 31.6 percent (12/38) of CRP patients demonstrated symptom resolution versus 24.4 percent (10/ 41) of sham patients ( P ϭ 0.48). Objectively, however, 34.2 percent of CRP-treated patients converted to a negative Dix-Hallpike at 1 week, versus 14.6 percent in the sham group ( P ϭ 0.04). Although statistically significant, this objective conversion rate is still lower than those reported among RCTs in the specialty setting (typically ranging from 66%-89%). 42 Because both the symptomatic response rates and conversion rates to a negative Dix-Hallpike maneuver are lower than those reported in specialty setting RCTs, further investigation into the effectiveness of the CRP in the primary care setting is warranted. Reasons for dis- crepancy between primary care and specialty settings may include differences in performance of the CRP (ie, a single maneuver vs repeated maneuvers at the same visit), intrinsic patient variability with comorbid balance disorders, differences in symptom reporting, or combina- tions thereof. The positive treatment results of the CRP have also been demonstrated in lesser quality nonrandomized trials and case series. 131-137 In addition to the Cochrane review, four meta-analyses have been reported. 41,138-140 Each analysis concluded that the CRP is significantly more effective than placebo in posterior canal BPPV. Among these trials, however, significant heterogeneity has also been demonstrated. 140 Many trials also report a secondary outcome of conversion from a positive to negative Dix-Hallpike maneuver after CRP. The odds ratios for this more objective measure of resolution for posterior canal BPPV range from 3.2 to 22 across studies, similar to reported rates of symptom resolution. 42 In most nonrandomized case series assessing treatment response, symptom resolution is the only commonly reported outcome measure for the CRP. Considerable variability exists in terms of the number of times the CRP is applied for the initial treatment of BPPV, even across RCTs. 59,128,129 Some investigators perform only one CRP cycle at the initial treatment, whereas others repeat a fixed number of cycles or perform the CRP repeatedly until the vertiginous symptoms extinguish or the Dix- Hallpike converts to negative. 128 Even further variability exists among published case series for CRP. 141-143 On the basis of a review of the literature, it was not possible to determine the optimal number of cycles for the CRP or a protocol for repeated procedures. The repeated application of the CRP is likely to be determined by the severity of the symptoms, if they persist; clinician availability; and the clinician’s historical success with the CRP. With respect to complications of treatment, CRP is associated with mild and generally self-limiting adverse effects in about 12 percent of those treated. 19 Serious com- plications from the CRP have not been identified in multiple RCTs. The most commonly encountered complications include nausea, vomiting, fainting, and conversion to lateral canal BPPV during the course of treatment (so-called canal switch). Such a canal switch occurs in about 6 to 7 percent of those treated with CRP, 129,144 underscoring the importance of recognizing the lateral canal variant of BPPV. Anecdotally, several investigators have suggested that the CRP should be applied cautiously in patients with cervical spine disease, certain vascular conditions, retinal detachment, and other contraindications to its performance. 145 Treatment with the liberatory (Semont’s) maneuver. Clinical trials concerning the treatment effectiveness of the liberatory maneuver (Fig 4) are limited. One study, 43 which included a treatment arm with the Semont maneuver, demonstrated that this maneuver improved vertigo intensity more than the sham treatment ( P Ͻ 0.009). A study by Salvinelli et al 146 randomized 156 patients to the Semont maneuver, flunarizine (a calcium channel blocker), or no treatment. At 6-month follow-up, symptom resolution oc- curred in 94.2 percent of patients treated with the Semont maneuver, 57.7 percent of patients treated with flunarizine, and 34.6 percent of untreated patients. Soto Varela et al 147 randomized patients 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%) but only 24 percent for Brandt-Daroff exercises. At 3-month follow-up, however, patients treated with CRP demonstrated superior outcomes compared with those treated with Semont maneuver ( P ϭ 0.027). In conclusion, the Semont maneuver is more effective than no treatment or Brandt-Daroff exercises in relieving symptoms of posterior canal BPPV, according to studies with small sample sizes and limitations. No adverse events have been reported in trials with the liberatory maneuver. Because of limited studies with direct comparisons between the liberatory maneuver and the CRP, no conclusions about differential effectiveness can be drawn. Lateral canal BPPV is usually unresponsive to CRPs used for posterior canal BPPV but may respond to other maneuvers intended to move canaliths from the lateral canal into the vestibule. 144,148,149 The roll maneuver (Lempert maneuver or barbecue roll maneuver) or its variations are the most commonly employed maneuvers for the treatment of lateral canal BPPV. 5,143 This maneuver involves rolling the patient 360 degrees in a series of steps to effect particle repositioning. It may be performed in the outpatient setting after a diagnosis of lateral canal BPPV has been made with the supine roll test. Rather limited data exist with respect to the effectiveness of the roll maneuver in lateral canal BPPV treatment. Based primarily on cohort studies and case series, the effectiveness of the roll maneuver in treating lateral canal BPPV appears to be approximately 75 percent, although reported response rates vary widely from 50 percent to almost 100 percent. 5,19,55,56,58,143,148-152 Because lateral canal BPPV may spontaneously remit more quickly than other forms of BPPV, a control group is especially important in assessing treatment efficacy. 51,142 Forced prolonged positioning is another treatment maneuver reported to be as effective in treating lateral canal BPPV. It may be performed either alone or concurrently with other maneuvers with a reported effectiveness of 75-90 percent based on case series. 58,150,152,153 Other lesser- known maneuvers such as the Gufoni maneuver and the Vannucchi-Asprella liberatory maneuver 151,154,155 have also been reported as effective in uncontrolled studies. In conclusion, variations of the roll maneuver appear moderately effective and are the most widely used treatments for lateral canal BPPV. Other methods of treatment have also been advocated, but currently no RCTs provide reliable measures of effectiveness. At this time, there is insufficient evidence to recommend a preferred treatment maneuver for lateral canal BPPV treatment. Three studies have assessed patient self-treatment for BPPV. One study found slightly greater improvement in those patients given instructions for self-administered CRP at home after initial CRP in the office. 156 Self-administered CRP appeared to be more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement). 157 Another study reported 95 percent resolution of positional nystagmus 1 week after self-treatment with CRP compared with 58 percent in patients who self- treated using a modified Semont maneuver ( P Ͻ 0.001). 158 No comparison studies have been published from which to make recommendations regarding self-treatment vs clini- cian-administered treatment of BPPV. In motivated individuals, self-treatment of BPPV may be an option. Comparison of studies, in particular the treatment arms for RCTs, reveals similar response rates whether or not posttreatment positional or activity restrictions (ie, cervical collar or positional avoidance) are observed. 43,59,128,129,159 Two studies looking at posttreatment restrictions after CRP found no evident improvement in those given restrictions. 160,161 Another study found slight benefit in patients with post-activity restrictions, as measured by the number of maneuvers required to produce a negative Dix-Hallpike maneuver. 162 Overall, there is insufficient evidence to recommend post-maneuver restrictions in patients treated with ...