The Epley Maneuver for BPPV Particle Repositioning
Many people with dizziness or vertigo have heard of the “Epley maneuver” as a treatment.
The Epley maneuver is used to reposition BPPV crystals.
It is the first procedure of its kind, published in the early 90’s by the late US-based physician named, John Epley. Since then, many healthcare providers and vertigo researchers around the world have developed a whole catalog of additional “particle repositioning maneuvers.”
In this blog, I discuss the top five reasons why the Epley maneuver may not be effective for BPPV treatment.
Incorrect Technique
First of all, many providers who are “dabbling” in vertigo care perform the maneuver incorrectly.
The Epley maneuver, the modified Epley, and all the particle repositioning maneuvers for BPPV require very precise, technically accurate performance to be effective. Unless the provider has studied the technique to reproduce precision and accuracy, they may be performing the Epley maneuver incorrectly.
In teaching this maneuver and other particle repositioning treatments to other providers, I have discovered certain predictable errors that are made by beginners. Those errors will reduce the effectiveness of the treatment.
Treating the Wrong Ear
Secondly, you have to treat the correct ear in order for the Epley maneuver to work.
The first step to effectively treating BPPV is to determine which ear is involved.
The options are right ear, left ear, or both ears. This can be determined through BPPV testing by a skilled provider.
I have been surprised how many times I have met a patient who described previous treatments to the “uninvolved ear” that obviously did not help at all, and in fact made them feel worse.
Treating the Wrong Semi-Circular Canal
There are three semi-circular canals in each inner ear. You must determine the canal that needs treatment.
The Epley maneuver is designed for the posterior canal.
If BPPV crystals are free-floating in the horizontal or anterior canal, then the Epley maneuver will not likely resolve the complaint.
Those other inner ear canals require different treatments that have been developed after the Epley maneuver was first published.
BPPV Crystals are Stuck
The BPPV particles can get stuck.
The Epley maneuver makes an assumption that the BPPV crystals are free-floating in the posterior canal of the ear being treated. However, there is a possibility that the BPPV crystals or debris can adhere to the sensory apparatus within the semi-circular inner ear canal called the “cupula.”
This is a type of BPPV called “cupulolithiasis,” as opposed to the more common “canalithiasis” with the free-floating crystals.
Cupulolithiasis is rare. In my experience treating literally thousands of people with BPPV, I have only found six people so far who have BPPV crystals stuck on their cupula.
It is possible to break the BPPV crystals off the cupula and resolve the problem, but starting with the Epley maneuver will not be effective in this case.
It’s not BPPV
The fifth reason that the Epley maneuver may not work is that you may not be dealing with BPPV.
There are other conditions that can mimic BPPV, even causing positional nystagmus and positional vertigo symptoms.
The five reasons I have listed above illustrate the importance of finding a skilled Vestibular provider to assess and treat your symptoms of dizziness, vertigo, and imbalance.
By doing this, the proper diagnosis can be assigned and the necessary care can be delivered effectively. You can get your life back!
Disclaimer
This blog is provided for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of any case mentioned in this post represent a typical patient that I might see and do not describe the circumstances of a specific individual.
great article, and very helpful.
Important reasons to seek help from an experienced professional .
Vertigo and dizziness contribute to falling. Vertigo has identifiable cause regarding the inner ear. What causes the dizziness? How can it be treated? Many falls are experienced from one or both conditions while wearing a helmet and using a four wheel walker.
Hi Will,
Yes, vertigo and dizziness definitely contribute to falling.
I have written this blog about what causes dizziness in the body.
There are many treatments for the various root causes of dizziness and vertigo.
On this page, I describe some of the treatments that are available today.
The key is to find a skilled provider to work with.
Sincerely,
Kim Bell, DPT
I was diagnosed with bppv right ear posterial canal ,have had Epley maneuvers and and dix halpike none helped ,I have balance issues with a back neck I can’t bend over and my eyes have something to do with it also
Hi Leanne,
It sounds like you have a situation that requires further investigation by skilled Vestibular provider.
You can use this blog to find a Vertigo Doctor in your area.
This blog on what to do when vertigo exercises don’t help may also be useful.
In this area of care, the most important thing is the results. I wrote this blog with three questions to ask when choosing a healthcare provider.
If your results are not satisfactory, then you may want to seek another opinion.
This blog and this blog outline the important reasons to seek skilled care without delay.
If you ever want to venture to San Diego, I would be happy to work with you in person.
I wish you all the best for a full recovery!
Sincerely,
Kim Bell, DPT
I am Menieres diagnosed. I had BPPV like spins when I would turn into my “bad” ear. The only treatment that helped to relieve my symptoms was treating it as a jaw\muscular issue. I know so many others who have been helped this way. I haven’t had vertigo for 32 months now and all the other miserable symptoms have gone too. Only tinnitus remains but livable. I think the medical community is doing a tremendous disservice by continually looking solely at these symptoms as vestibular or neuro. Look at the way we live. Our necks, heads , backs upper arms, front of chest are in positions day in an out that they are not meant to be in. When you turn into a muscle in spasm it causes spins. If you have them in spasm continually the messages delivered through the ear gets screwed up. Please, this needs to be considered and tested so that people stop suffering and get their lives back.
Hi Beth,
What a great story! I am so happy to hear that you haven’t had vertigo for 32 months now!
Perhaps soon, you will be counting in years instead of months?!
I completely agree with you about the disservice to people suffering with dizziness and vertigo by only treating it as a neurological or vestibular problem.
That is why I developed my own comprehensive, unique methodology of evaluating and treating these complaints, called “The Bell Method.”
With my patients, I perform a comprehensive, multi-system analysis to determine the root cause of their symptoms.
Sadly, many patients spend months to years going from one specialist to the next without ever determining the root cause of their problems. A lot of providers are subject to tunnel vision.
I am completely with you on the importance of considering the neck and jaw muscles, bones, and fascia in determining any musculoskeletal contribution to the cause of dizziness, vertigo, balance problems, and tinnitus.
Thank you for adding your input to this important conversation and sharing your success story!
With gratitude,
Kim Bell, DPT
I’m very surprised to hear you have only seen 4 cases of cupulolithiasis. We see it on a fairly regular basis in our practice in both the horizontal and posterior canals.
Hi Margaret,
Thank you for sharing your clinical experience treating patients at your PT clinic in Pennsylvania, USA.
In fact, I just had two more recent patients with cupulolithiasis, so my total is now up to 6. (I will go ahead and update the blog now to reflect that number.)
Six is still a very low number in a sample size of somewhere around 5,000 cases of BPPV that I have treated to date.
You may be also interested in reading this webpage by Dr. Timothy Hain, MD who reports only 8 confirmed cases of cupulolithiasis in his practice database of 25,000 patients as of 2019.
I think your point illustrates the importance of avoiding the use of anecdotal evidence to drive our understanding of epidemiological trends and population data.
Although we are treating a similar population, we have clearly had different patients come across our path.
The good news is that they have arrived at the right place and the right time to receive our skilled Vestibular care!
It is a pleasure to be out here in the trenches alongside you changing lives, one at at time!
Warmest regards,
Kim Bell, DPT
” It is possible to break the BPPV crystals off the cupula and resolve the problem, but starting with the Epley maneuver will not be effective in this case. ”
What should be used to break them free?
Hi Berat,
There are a few treatment techniques that can be used to break them free.
I cannot advise you which would be best, because each case is different.
My suggestion is to find a skilled Vestibular Provider to evaluate the situation in person, then recommend the most appropriate treatment.
You can use this link to find a Vertigo Doctor in your Area.
Best wishes,
Kim Bell, DPT
Have you experienced a patient having downbeating nystagmus without having anterior canal BPPV, but instead having multiple other canals affected by crystals?
If so , can you give me an example?
I have downbeating nystagmus/slightly horizontal left due central reasons probably, but i also have BPPV.
When put in Dix-hallpike position right side my nystagmus ( downbeating ) increases very, but left on the left side it decreases even tho it`s still there. I go to one of the best vestibular therapist in my country, but even he struggles a little because of the intensity of the DBN.
I have been treated on the left anterior, right anterior with no relevant results.
I got treated in the horizonal-right canal with huge results, but the DBN still remains even tho it has decreased sometimes it spikes. I got a little bit of horizontal- nystagmus left that indicates that the right-horiszontal canal is not clear of crystals yet.
My question really is if it is possible that the DBN can come from having crystals in the posterior canal also or maybe both posterior canals?
Sorry for this long comment, but my case is really difficult so i was hoping you maybe have some answers that can help.
Hi Berat,
I am so happy to hear that you are working with a highly skilled Vestibular Physical Therapist!
The answer to your question is yes, I am very familiar with all types of nystagmus presentations, both typical and atypical.
If you would like to consult with me on your individual case, I invite you to travel to San Diego so I can evaluate you in person, establish a therapist-patient relationship with you, and subsequently offer individual medical advice regarding the details you described.
You can learn more about my services, along with answers to frequently asked questions here.
All my best,
Kim Bell, DPT