# 2014 Comparative study of the efficacy of the canalith repositioning

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Acta Oto-Laryngologica. 2014; 134: 704–708
ORIGINAL ARTICLE
Comparative study of the efficacy of the canalith repositioning
procedure versus the vertigo treatment and rehabilitation chair
JUN TAN, DONGZHEN YU , YANMEI FENG, QIANG SONG, JIN YOU, HAIBO SHI &
SHANKAI YIN
Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
Abstract
Conclusion: Vertigo treatment and rehabilitation chair (TRV) may be suggested as the first choice for patients with posterior
canal benign paroxysmal positional vertigo (p-BPPV). Objective: To investigate the short- and long-term treatment efficacy of
the canalith repositioning procedure (CRP) versus TRV for patients with p-BPPV. Methods: A total of 165 patients with
unilateral p-BPPV were assigned to either the CRP group or the TRV group. Patients were assessed at 1 week, 4 weeks,
3 months, and 6 months after their first treatment. The numbers of treatment sessions required for successful repositioning in
both groups at 4 weeks, 3 months, and 6 months were recorded. Results: Treatment efficacy of patients in the TRV group was
significantly better than that of patients in the CRP group 1 week after the first treatment. The number of treatment sessions
needed for successful repositioning was significantly lower in the TRV group than in the CRP group at 4 weeks and 3 months
after the first treatment.
Keywords: Vertigo, short-term efficacy, recurrence
Introduction
Benign paroxysmal positional vertigo (BPPV) is a
common vestibular disorder leading to repeated
episodes of a spinning sensation produced by changes
in the head position relative to gravity [1]. Posterior
canal BPPV (p-BPPV) is the most common variant of
BPPV, constituting ~85–95% of cases [2]. The
canalith repositioning procedure (CRP, also referred
to as the Epley maneuver), which was first described
by Epley in 1992, is most commonly used to treat
p-BPPV [1,3].
The success rate of CRP for p-BPPV is reportedly
66–89% [4]. Although the success rate is remarkably
high, patients with BPPV without symptom improve-
ment still comprise a large proportion of all patients
with BPPV when one takes into account that BPPV
has a lifetime prevalence of 2.4% and accounts for 8%
of individuals with moderate or severe dizziness/
vertigo [5,6]. In addition, a small fraction of patients
experience a high frequency of BPPV attacks even
after repeated repositioning maneuvers [7]. These
difficult cases are often encountered among patients
who are unable to physically tolerate and cooperate
with the physicians’ repositioning maneuvers [8].
Some patients with neck disorders may have difficulty
in facilitating the repositioning maneuvers because of
their limited range of flexion-extension movement
[9]. Patients with limb disabilities or back disorders
also may not be able to physically tolerate the repo-
sitioning procedure [10]. In addition, patients who
cannot tolerate the violent vertiginous symptoms
resulting from the maneuver process may fail to
complete the therapeutic procedure [11].
It seems that in these cases, the ideal therapeutic
position and plane relative to the semicircular
canals are difficult to achieve because of the above-
described conditions. CRP can neither be physically
performed appropriately nor successfully resolve the
symptoms.
Correspondence: Dongzhen Yu and Haibo Shi, Department of Otolaryngology, Affiliated Sixth People’s Hospital of Shanghai Jiao Tong University, 600 Yishan
Road, Shanghai 200233, China. Tel: +86 21 24058706. Fax: +86 21 64834143. E-mail: sjtuorl_hns@163.com; haibo99@hotmail.com
(Received 27 November 2013; accepted 10 February 2014)
ISSN 0001-6489 print/ISSN 1651-2251 online � 2014 Informa Healthcare
DOI: 10.3109/00016489.2014.899711
Because of all of the above factors, the vertigo
treatment and rehabilitation chair (TRV) combined
with the use of videonystagmoscopy goggles has been
brought into clinical use. The purpose of our study
was to compare the efficacy of TRV with that of CRP
in patients with p-BPPV.
Material and methods
Patients
This prospective study included 165 patients with
unilateral p-BPPV who were examined and treated
at the Department of Otolaryngology of the Affiliated
Sixth People’s Hospital of Shanghai Jiao Tong
University between February 2011 and April 2012.
All patients underwent complete otolaryngologic
and neurotological evaluations. The diagnosis of
p-BPPV was made by previous criteria [12]. Patients
with horizontal or anterior canal BPPV, multiple
canal BPPV, or bilateral multiple canal BPPV at their
first visit were excluded from this study. Patients who
did not return for positional testing at the specified
time points were also excluded.
Study design
Patients were assigned to treatment with CRP (n = 84)
or TRV (n = 81). The two groups did not differ
with respect to clinical and demographic baseline
characteristics (Table I).
CRP for p-BPPV was performed following the steps
below. Patients were rapidly laid back from the upright
position with the head turned 45� toward the affected
ear. After 30 s, the head was rapidly turned 90� to the
unaffected side without elevating the head (thus facing
45� toward the unaffected side). After 30 s, the head
was turned by a further 90� to the unaffected side after
the patient had rolled the trunk on this side. Finally,
after waiting another 30 s, the patient was brought into
an upright sitting position.
The vertigo treatment and rehabilitation chair
(SYNAPSYS, Marseille, France) combined with
videonystagmoscopy (SYNAPSYS) were used in
this study. The chair, which has two axes of full
360� rotation that are lockable in preset positions,
can rotate the patient in any plane, while the video-
nystagmoscopy allows for constant monitoring of eye
movement. Patients were fitted with eye goggles with
a small built-in infrared video camera. The goggles
were well stabilized on account of the fact that the
head was kept stationary in relation to the body.
The repositioning maneuver of TRV was made fol-
lowing the steps below (Figure 1). Patients were turned
on the vertical axis at an angle of 45� from the side
opposite the affected side and then tilted to the affected
side at45� to thehorizontal plane.Eachpatientwasheld
in thisposition for1min. (Thispositionalways triggered
a vertigo attack accompanied by nystagmus typical of a
1 2 3 4
Figure 1. Repositioning maneuver of vertigo treatment and rehabilitation chair (TRV).
Table I. Demographic and clinical features of patients with p-BPPV.
Feature CRP (n = 84) TRV (n = 81) p value
Sex ratio (male/female) 21/63 23/58 0.622
Mean age (years) ± SD 55.13 ± 11.20 52.51 ± 11.35 0.151
Affected side (left/right) 32/52 35/46 0.504
Median duration of episode in days (range) 30 (1–3650) 30 (1–4015) 0.588
Idiopathic BPPV* 55/29 57/24 0.501
CRP, canalith repositioning procedure; p-BPPV, posterior canal benign paroxysmal positional vertigo; TRV, vertigo treatment and
rehabilitation chair.
*No history of acute vestibular loss, migraine, Ménière’s disease, or head trauma within 6 months before onset of BPPV.
Comparative study of the efficacy of CRP vs TRV 705
disorder of theposterior canal during thefirstmaneuver
in every patient.)The vertical axiswas then rotated180�
to the healthy side, and the patient was left in this
position for ~1 min. The patient was then brought
into an upright sitting position.
One treatment procedure visit was defined as one
treatment session. In both groups, CRP or TRV was
repeated four times during one treatment session.
A vibrator was not used. Patients did not receive
post-treatment instructions to stay upright.
Evaluation of treatment
Patients were assessed 1 week, 4 weeks, 3 months, and
6 months after their first treatment. Successful treat-
ment was defined as the absence of positional vertigo
and nystagmuson the positional test. During our
required follow-up interval, patients who complained
of recurrence of positional vertigo were also recom-
mended to visit our outpatient department. If nystag-
mus could be provoked by the Dix-Hallpike maneuver
during the follow-up, they were treated again with the
same maneuver that they underwent in their first
treatment. All patients were re-examined 1 week after
each treatment until the positional test result was
negative. The numbers of treatment sessions required
for successful repositioning in both groups at 4 weeks,
3 months, and 6 months were recorded.
Statistical analysis
All numeric data were compared using the c2 test,
whereas measurement data were compared using the
t test. Level of significance was defined as a
p value < 0.05. Statistical analyses were performed
using PASW Statistics, version 17.0 (IBM SPSS,
Armonk, NY, USA).
Results
At the end of 1 week, 61 of the 84 patients in the CRP
group (72.6%) had negative responses to the Dix-
Hallpike test. In contrast, 69 of the 81 patients in the
TRV group (85.2%) had negative responses to the
Dix-Hallpike test. A statistically significant difference
was noted between these two groups (Table II).
However, similar treatment results were obtained at
4 weeks, 3 months, and 6 months between the two
groups because no statistically significant difference
was found (Tables II and III).
Table IV shows the number of treatment sessions
needed for successful repositioning. This number was
lower in the TRV group than in the CRP group at
4 weeks, 3 months, and 6 months. The group differ-
ence was significant (p < 0.05) at 4 weeks and
3 months, but not (p = 0.1) at 6 months.
During the last 6-month follow-up, all patients in
both groups had been cured at least once. All patients
with recurrence reported that their sensation of ver-
tigo was less severe than that at their first visit to our
department. Slight side effects appeared, including
transient nausea and sweating, in 10 and 12 patients
in the CRP and TRV groups, respectively.
Discussion
In the present prospective study, the patients in the
two groups were comparable because they did not
Table II. Treatment outcome in patients with p-BPPV at 1 and 4 weeks.
1 week 4 weeks
Dix-Hallpike maneuver CRP (n = 84) TRV (n = 81) p value CRP (n = 84) TRV (n = 81) p value
Positive 23 (27.4%) 12 (14.8%) 4 (4.8%) 6 (7.4%)
Negative 61 (72.6%) 69 (85.2%) <0.05 80 (95.2%) 75 (92.6%) 0.7
The chi-squared test was used for statistical analysis. CRP, canalith repositioning procedure; p-BPPV, posterior canal benign paroxysmal
positional vertigo; TRV, vertigo treatment and rehabilitation chair.
Table III. Treatment outcome in patients with p-BPPV at 3 and 6 months.
3 months 6 months
Dix-Hallpike maneuver CRP (n = 84) TRV (n = 81) p value CRP (n = 84) TRV (n = 81) p value
Positive 3 (3.6%) 4 (4.9%) 4 (4.8%) 2 (2.5%)
Negative 81 (96.4%) 77 (95.1%) 0.961 80 (95.2%) 79 (97.5%) 0.711
The chi-squared test was used for statistical analysis. CRP, canalith repositioning procedure; p-BPPV, posterior canal benign paroxysmal
positional vertigo; TRV, vertigo treatment and rehabilitation chair.
706 J. Tan et al.
differ with respect to clinical or demographic baseline
characteristics (Table I).
Our results show that at 1 week after treatment, the
percentage of cured patients who had negative
responses to the Dix-Hallpike test was significantly
higher in the TRV group than in the CRP group
(85.2% vs 72.6%, respectively). We speculate that
this significant difference might have been caused by
the poor cooperation of some patients in the CRP
group. The ideal therapeutic position was difficult to
achieve in these patients, who had limb disabilities or
neck disorders [9]. However, the patients in the TRV
group were rotated as one unit while their bodies were
kept stationary relative to the chair. Thus, the ideal
therapeutic position and plane could always be
achieved and repeated as needed. The significant
difference between these two groups at 1 week shows
that TRV was more effective than CRP after one
treatment session.
At 4 weeks, 3 months, and 6 months after treat-
ment, no significant difference in the cure rate
between the TRV and CRP groups was found.
A possible reason for the lack of a significant differ-
ence was that the success rates of both treatment
options were remarkably high. Patients with repeated
vertigo attacks during the re-examination interval
could finally achieve a cure after proper and sufficient
treatment. In addition, the disease course of BPPV is
self-limiting. Imai et al. found a mean time interval
from onset of symptoms to spontaneous resolution of
BPPV of 39 ± 47 days in patients with untreated
BPPV [13]. Thus, the cure rates of both groups at
4 weeks, 3 months, and 6 months were similar.
Furthermore, significantly fewer treatment sessions
were needed for successful repositioning in the TRV
group than in the CRP group at 4 weeks and 3months.
These findings provide further evidence that treat-
ment of p-BPPV with TRV is more effective than
CRP during a short-term follow-up. TRV saves con-
siderable time, money, and inconvenience for the
outpatient. Fewer treatment sessions and better
short-term efficacy translate into a lower risk of fall-
ing, higher productivity, increased daily activity, and
better quality of life [14,15]. Although no statistically
significant difference was found between the two
groups at 6 months, a study involving a larger sample
is needed to establish whether any difference exists.
Two studies have used repositioning devices similar
toours [8,9].However, patientswithBPPVwhounder-
went the standardEpleymaneuverwere not available in
their study as a control group [8]. Also, no statistical
analysis was conducted between the treatment group
and control group as regards demographic and clinical
features [9]. In the present study, the sample size was
relatively large and careful statistical analysis was con-
ducted. In addition, no follow-up end point was set in
the other two studies, and it seemed that both studies
were conducted until no further improvement could be
achieved in patients with BPPV after four or more
treatment sessions [8,9]. In the present study, the
follow-up strategy was clear and patients were assessed
1week, 4weeks, 3months, and6months after theirfirst
treatment session.
Observation of nystagmus is essential for an accu-
rate diagnosis and proper treatment, especially in
cases in which the nystagmus findings are suggestive
but not clear and in which mild nystagmus goes
unnoticed with the naked eye but becomes evident
on examination with Frenzel lenses or nystagmogra-
phy [16,17]. It would be more beneficial to use
videonystagmoscopy to record nystagmus associated
with p-BPPV because the eye movement can be dis-
played and enlarged on the screen to increase the level
of detail, and images of eye movements can be saved
and replayed for further comparison of their clinical
course. However, it was difficult to apply videonys-
tagmoscopy goggles during the manual positional test
and repositioning maneuver because patients moved
during the procedure and the image of eye move-
ments was not stable. TRV in combination with
videonystagmoscopy goggles made it possible for
patients to be placed in an ideal therapeutic position
and plane repeatedly as needed and for physicians to
diagnose and treat BPPV cases with more accuracy.
In conclusion, TRV is a safe and effective treatment
option for patients with p-BPPV. Greater treatment
efficacy and fewer treatment sessions could be
achieved with TRV than with CRP. TRV could be
suggested as the first choice for patients with p-BPPV.
Acknowledgments
This work was supported by Key Projects in the
National Science & Technology Pillar Program dur-
ing the Twelfth Five-year Plan Period from the
National Health andFamily Planning Commission
of China (no. 2012BAI12B00/2012BAI12B01) and a
Table IV. Mean numbers of CRP and TRV required for successful
repositioning at 4 weeks, 3 months, and 6 months.
Time
CRP group
(n = 84)
TRV group
(n = 81) p value
4 weeks 1.39 ± 0.62 1.20 ± 0.46 0.023
3 months 1.55 ± 0.86 1.31 ± 0.68 0.039
6 months 1.60 ± 0.98 1.38 ± 0.75 0.1
CRP, canalith repositioning procedure; TRV, vertigo treatment and
rehabilitation chair.
Comparative study of the efficacy of CRP vs TRV 707
grant from Shanghai Municipal Commission of
Health and Family Planning (no. 2013SY040).
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
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	Abstract
	Introduction
	Material and methods
	Patients
	Study design
	Evaluation of treatment
	Statistical analysis
	Results
	Discussion
	Acknowledgments
	Declaration of interest
	References