Epley maneuver: Why is this the best protection from the symptoms of vertigo?

What is the Epley maneuver?

Epley maneuver is an exercise that can treat the symptoms of benign paroxysmal positional vertigo (BPPV).  It was designed by Dr. John Epley.  The main purpose of this exercise is to move the crystals from the semicircular canals back to the utricle where they actually belong.  Initially, this exercise maneuver was designed to be performed under the guidance of your doctor, but these exercise maneuvers are done even by an individual at home.

The main cause of BPPV is due to a problem in the inner ear.  The semicircular canal that is present inside the ear is responsible to detect motion and send this information to the brain.  The utricle is an otolith organ that is near the ear and contains calcium crystals called canaliths and help detect movement.

During certain circumstances, these crystals detach from the utricle and move towards the semicircular canals.  When these crystals are inside the semicircular canals, incorrect signals are relayed to the brain about the position.  This causes confusion in the brain to determine the position of your head and can cause a spinning sensation called vertigo.

Facts on vertigo

• It has been estimated by the Vestibular Disorders Association (VEDA) that 1 out of 1000 individuals is affected by benign paroxysmal positional vertigo (BPPV).
• An inner ear infection is considered to be the leading cause of vertigo symptoms that causes imbalance because of the fluid present in the inner ear.
• University of California San Francisco Medical Center has determined that around 40% of the adults in the United States experience vertigo symptoms at least once in their lifetime.
• Studies have found that women are more susceptible to vertigo as compared to men.

What is the utility of the Epley maneuver?

As discussed earlier, you may need to try the Epley maneuver if you are suffering from symptoms of BPPV.  BPPV symptoms can strike at any time.  There is no particular time or situation for it to occur.  The symptoms generally last for a minute or two but can lead to other complications such as head trauma due to a fall.  In some cases, it may also be associated with nausea and vomiting.

Generally, the symptoms are instantaneous without any known cause, but sometimes can be caused due to a medical condition such as head injury, following ear surgery, etc.  Epley maneuver is suggested by your doctor if you have recurrent attacks of BPPV.  Since it is quite easy to follow and is also effective in treating the symptoms, this exercise can be carried out in the comfort of your home.

An initial presentation replicating the Epley maneuver is displayed in the doctor’s office.  You will also be given some handouts to refer later to your home if you have any confusion in performing the exercise.  This exercise can be helpful if a vertigo attack occurs anytime in the future.

Diagnosis of vertigo

The diagnosis of BPPV is done by performing a physical examination and determining the cause of the dizziness.  The doctor will then determine the medical history of the patient and check if the patient is suffering from any health conditions such as migraine headache or has undergone recent surgery to the head.  The doctor will also check if the patient has had any trauma to the head.  Next, the patient will need to undergo a CT or MRI scan of the head to further analyze the cause.  The following tests are conducted to confirm the diagnosis of vertigo.

Nystagmus testing:  This test is performed by inducing nystagmus, as this is one of the factors that can cause vertigo.  You may experience nystagmus when you try to focus on a particular position when something is passing quickly such as looking out from a train window.  The test is conducted by carrying out the following exercise:

• The patient is moved rapidly from a sitting to lying down position on the examination table with the head turned at 45 degrees toward the affected side.
• Next, the head is moved 30 degrees over the end of the table, making sure it is below the horizontal position of the rest of the body.

If the doctor observes any specific eye movements or if the patient experiences vertigo, this can confirm the diagnosis.  Once diagnosed, this can be confirmed with further tests such as:

• Electronystagmography (ENG): This test can record the nystagmus electronically.  During this test, the patient needs to wear a headset that places electrodes around the eyes, helping the device to calculate eye movements.
• Videonystagmography (VNG): This is the latest type of test that enables video recording of the nystagmus.  The patient is subjected to wear a pair of special glasses that contain video cameras. Infrared light is used to record horizontal, vertical, and torsional eye movements.  This recording is finally analyzed with the help of a computer.

The head impulse test:  This test is performed to find out if the problem is associated with the ear or due to other causes such as problems with the central nervous system namely blood clots in the brain or narrowing of the blood vessel.

During this test, the patient is asked to focus on the tip of the doctor’s nose while the head is moved quickly to a particular side.  If the patient is able to retain the focus on the nose while moving quickly, the test is confirmed to be negative.  The test is considered to be positive if the patient is not able to focus the eyes on the examiner’s nose during the quick head movement.  This maneuver is attempted on both left and right side to determine the affected ear.  However, it should be noted that a positive test can also occur due to a central nervous system problem.

Romberg’s test:  This is a very simple test where a person who is standing steady with arms placed at the sides, feet together, and eye open is asked to shut the eyes.  If the person becomes unsteady and falls on a particular side, it is considered to be a positive test.  The side on which the person falls is considered to be the affected side.

Unterberger’s test:  This test is performed by asking the patient to march on the spot for 30 seconds with the eyes closed.  This may cause a sideways rotation toward the affected side if peripheral vertigo is present, confirming the diagnosis.

How to correctly perform an Epley maneuver?

• Make the patient sit upright on an examination table with the legs extended in the front.
• Next, rotate the patient’s head to a 45-degree angle towards the side where the patient is experiencing vertigo.
• Now quickly make the patient lie down on the examination table with the patient’s shoulders placed on the pillow and allowing the head to stay in a reclining position. The patient will stay in the same position for a period of 30 seconds to 2 minutes until the dizziness stops.
• Then, rotate the patient’s head 90 degrees in the opposite direction. Again, retain this position for a period of 30 seconds to 2 minutes until the dizziness stops.
• Now roll the patient’s head and the body simultaneously together in the same direction that the patient is facing. The doctor will hold the patient in the same position for a period of 30 seconds to 2 minutes until the dizziness stops.
• Finally, the patient is allowed to come back to the sitting position.

This maneuver is repeated at least three times until the patient’s symptoms are relieved.

How is it performed at home?

It will be helpful if you have watched a video or a demonstration done by a professional about Epley maneuver.  You can also read a brochure with pictures depicting the postures.  How often you need to perform this exercise depends on the severity of your symptoms.  Your doctor may ask you to perform the exercise at least three times a day until your symptoms do not return for 24 hours.

Steps to be followed if the problem is with your right ear:

• Choose a comfortable bed and then sit down to start the exercise.
• Next, turn your head to approximately 45 degrees on the right.
• Immediately lie back on the bed with the position of the head turned towards the right side at 45 degrees. Be sure to place your shoulders on the pillow so that your head should be reclined.  Stay in the same position for 30 seconds.
• Next, at the same position of your body, turn your head 90 degrees to the left, without raising it. This should make your head to be facing 45 degrees to the left.  Stay in the same position for 30 seconds.
• Now simultaneously turn your head and body another 90 degrees towards the left while lying on the bed. Again, stay in the same position for 30 seconds.
• Finally, sit up on the left side.

Steps to be followed if the problem is with your left ear:

• Start your exercise by sitting on a bed in a comfortable position.
• Next, turn your head to approximately 45 degrees on the left.
• Immediately lie back on the bed with the position of the head turned towards the left side at 45 degrees. Be sure to place your shoulders on the pillow so that your head should be reclined.  Wait for 30 seconds in the same position.
• Next, at the same position of your body, turn your head 90 degrees to the right, without raising it. This should make your head to be facing 45 degrees to the right.  Wait for 30 seconds in the same position.
• Now simultaneously turn your head and body another 90 degrees towards the right while lying on the bed. Again, wait for 30 seconds in the same position.
• Finally, sit up on the right side.

After the Epley Maneuver

• If the exercise was performed in your doctor’s office, you would need somebody to drive you home, as you may still feel a bit dizzy from the incident. It is highly risky to self-drive due to the possibility of recurrence.
• It is highly recommended to not lie flat for at least 48 hours after the maneuver. You may use a couple of pillows to elevate your head when sleeping or resting.
• Do not bend your head forward during activities such as brushing your teeth or tying your shoelace for the next 48 hours after the maneuver. Maintaining the position of your head still for at least 48 hours would allow the canaliths to settle in the utricle and not move back to the semicircular canal.
• Regular day to day activities can be carried out by making sure to keep your head upright.
• You may require returning to your doctor’s office for a follow-up.

Risks

Epley maneuver is generally considered safe even when practiced at home.  There may be certain cases where the patient may feel nauseated and even vomit during the maneuver.  On the other hand, a certain medical condition can restrict a person from practicing this maneuver due to the inability to move the body such as neck or back problems, retinal detachment, vascular conditions, etc.  Medical supervision would be preferred in such a situation.

References

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