This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
This study aimed to compare the effects of two home-based exercises, the self-Epley maneuver (SEM) and Brandt-Daroff exercise (BDE), in patients with posterior canal benign paroxysmal positional vertigo (BPPV).
Methods
A total of 50 outpatients with unilateral posterior canal BPPV, a documented positive Dix-Hallpike test, and symptoms of vertigo for a duration of at least 1 week were randomized into the SEM and BDE groups. Patients in both groups performed home-based exercises for a total duration of 2 weeks. The primary outcome was vertigo resolution at 1 and 6 months. Secondary outcomes included conversion of a positive to a negative Dix-Hallpike test at 1 month and reduction in vertigo intensity and Dizziness Handicap Inventory (DHI) scores at 1 month and 6 months.
Results
Vertigo resolution was achieved in 40% of the patients at 1 month and in 48% at 6 months in both groups. The conversion rates from positive to negative Dix-Hallpike test at 1 month were 92% and 84% in the SEM and BDE groups, respectively. There was a significant reduction in the vertigo intensity and an improvement in the mean DHI score. Both SEM and BDE were well tolerated, with a few minor complications, such as transient dizziness and nausea.
Conclusion
Both SEM and BDE are effective for treating posterior canal BPPV. Although there was no significant resolution of the vertigo, there was a reduction in its intensity and a perceived decrease in its negative impact on daily life.
Benign paroxysmal positional vertigo (BPPV) is a disorder of the inner ear characterized by short episodes of vertigo provoked by changes in the head position relative to gravity [1]. The posterior semicircular canal is the most commonly affected site, accounting for 85%–95% of cases, with 85% of reported cases being unilateral and usually attributed to canalithiasis. The horizontal or lateral semicircular canal accounts for the remaining 5%–15% of cases, but its pathophysiology is not as well understood as that of posterior canal BPPV [1,2]. The diagnosis of BPPV can be made clinically based on a history of recurrent vertigo episodes triggered by changes in head position, as well as the presence of characteristic nystagmus during the Dix-Hallpike test (DHT; a positive DHT), according to the guidelines of the American Academy of Otolaryngology-Head and Neck Surgery [1].
BPPV is the most common vestibular disorder in adults with a lifetime prevalence of 2.4% [1,3,4]. Data from our center, the Universiti Malaya Medical Center (UMMC), showed that out of 100 patients referred to a neurotology specialist clinic with complaints of dizziness, 66% had a peripheral vestibular disorder, of which 31% were diagnosed with BPPV [5]. BPPV among patients aged <50 years is most commonly caused by head injury, whereas in patients aged >50 years, it is primarily attributed to degeneration of the vestibular system of the inner ear [6]. Although vertigo symptoms may resolve spontaneously and only recur months later, they can still be debilitating enough to warrant visits to primary care and specialized tertiary clinics.
Habituation exercises, such as the Brandt-Daroff exercise (BDE) and particle repositioning maneuvers (PRM), including the Epley, Semont liberatory, and Gans maneuvers, have been recognized as effective treatments for posterior canal BPPV [1,2,7]. Although BPPV generally resolves spontaneously, studies advocate the use of PRM to facilitate faster recovery of symptoms, prevent deleterious complications such as falls, and enable an earlier return to activities of daily living [1–3,6,7]. In most cases, the symptoms resolve after a single PRM. However, in certain high-risk patients, symptoms may persist and repeated PRMs may be necessary. Therefore, home-based exercise programs can be beneficial in reducing the need for frequent clinic visits.
The BDE is one of the most common habituation exercises prescribed, whereas the Epley maneuver is the most frequently applied PRM for patients with a positive DHT. Both the BDE and Epley maneuver have been well studied over the last 20 years, with evidence supporting the superiority of the Epley maneuver over BDE [1]. However, there is conflicting evidence regarding whether the self-Epley maneuver (SEM) is superior to the BDE.
The original 1980 Brandt-Daroff study reported a 98% conversion rate from positive to negative DHT at 2 weeks [8]. In contrast, Radtke et al. [9] in 1999 reported a much lower 23% success rate. A 2010 systematic review by Helminski et al. [10] analyzing three quasi-randomized controlled trials revealed a 1-week conversion success rate of 90% for SEM and 24% for BDE. It was concluded that BDE was only 0.13 times as likely to resolve BPPV symptoms compared with SEM. However, in the same year, Cohen and Sangi-Haghpeykar [11] reported that SEM was as effective as modified BDE.
Most efficacy studies have focused primarily on vertigo resolution or conversion rates of the DHT as outcome measures. While these two measures are important for assessing efficacy, other aspects such as vertigo intensity and the overall impact of dizziness on daily activities should also be examined. Therefore, this study aimed to compare the efficacies of two home-based exercises, SEM and BDE, in patients with unilateral posterior canal BPPV. The primary outcome measure was vertigo resolution, while the secondary outcome measures included reduction in vertigo intensity, conversion of a positive to a negative DHT, and reduction of the impact of dizziness on daily life, as assessed using the Dizziness Handicap Inventory (DHI) questionnaire.
Methods
Study design and setting
This was a prospective, single-blind, randomized controlled study involving a cohort of patients diagnosed with unilateral posterior canal BPPV who were referred for rehabilitation within a 1-year period. Patients were referred from several outpatient specialist clinics at UMMC, primarily from (1) the neurotology clinic, which is a specialized tertiary clinic managed by otorhinolaryngologists, and (2) family medicine specialist clinics.
Ethical considerations
All the procedures were performed in accordance with the ethical standards of the Declaration of Helsinki. The study protocol was approved by the UMMC and Research Ethics Committee (MREC ID no., 20155-1337). Trial registration was completed at ClinicalTrials.gov (https://clinicaltrials.gov/show/NCT03230513).
Participants
All patients referred from clinics for home-based exercises were screened. The inclusion criteria were as follows: symptoms of vertigo for at least 1 week, documented positive DHT at the time of referral, intact cognitive function, and the ability to communicate and understand instructions for performing home-based exercises. Patients were excluded if they had a history of prior ear surgery, orthopedic or connective tissue disorders affecting functional neck or trunk range of motion, significant neurological disorders, spinal cord damage, or previous prescription of home-based exercises for BPPV. Informed consent was obtained from all participants.
Randomization and allocation concealment
Block randomization was conducted using computer-generated numbers in blocks of 10, created using Microsoft Excel (Microsoft Corp.). A sealed envelope containing an instruction pamphlet for either SEM (designated as “Group A”) or BDE (designated as “Group B”) was provided to each patient to indicate their group allocation. All envelopes were arranged in a randomized sequence and maintained by the assistant in charge. At the beginning of each block, the assistant randomly chose the block order. The assistant then provided the envelope taken from the top of the set to each patient, which was subsequently handed over to one of the three dedicated vestibular physiotherapists assigned to this study.
Blinding
The primary investigator (PI) was blinded to the interventions assigned to each patient. All the patients were interviewed before being handed over to an assistant for group allocation. The assistant maintained a list containing the names of patients and their group allocations for reference. This list was made available to the PI only after completion of the 6-month assessment. Both interventions consisted of a series of similar head and body movements that the patients were required to perform for 2 consecutive weeks. Patients were unaware of the names of the exercises prescribed.
Interventions
Self-Epley maneuver group
Group A was assigned to the SEM [12] which is a modification of the Epley maneuver developed by Epley [13]. For the SEM, the patients should position themselves in a long sitting position on the bed and then turn their head 45° toward the problematic side. While keeping this head position, they should then lie supine with a pillow placed under their shoulders. Next, they turn their heads 90° in the opposite direction, followed by turning their bodies to the same side before returning to a sitting position at the edge of the bed. Each position was held for 30 seconds, and the patient was required to perform three cycles of this maneuver just prior to going to bed daily for 2 weeks.
Brandt-Daroff group
Group B was the BDE group developed by Brandt and Daroff [8]. For BDE, the patient must sit at the edge of the bed, turn his head 45° laterally to one side, and move rapidly into a side-lying position, while keeping his head in the same position. He then returns to the upright position and turns his head in the opposite direction, and the same movement is repeated on the other side. Each position was held for at least 30 seconds, and the patient was required to perform five repetitions, 3 times a day, daily for 2 weeks.
The patients were provided with training and observed under the supervision of a rehabilitation physician or physiotherapist in a single session prior to initiating the intervention. During this session, patients were instructed on the proper technique and sequence of movements for their assigned exercises (SEM or BDE). To ensure comprehension and adherence, the patients were given detailed written instructions accompanied by pictorial illustrations sourced from online resources. These instructions have been compiled in a leaflet for ease of reference.
Outcomes
The primary objective of this study was to compare the efficacies of SEM and BDE in resolving vertigo symptoms at 1 and 6 months in patients with unilateral posterior canal BPPV. Secondary outcome measures included comparison of the conversion of positive to negative DHT results between both groups after 1 month, assessment of vertigo intensity in patients with unresolved vertigo at 1 and 6 months, and comparison of the DHI scores between both groups at 1 and 6 months.
Once enrolled in the study, patients’ baseline data were recorded, including demographic information, symptoms of vertigo, use of pharmacotherapy, and existing comorbidities. Patients were asked to rate the average severity or intensity of their vertigo episodes over the previous week using a 1–5 Likert scale, with 5 indicating the most intense or severe episodes. Additionally, the patients were asked to complete the DHI questionnaire, an outcome measure used to evaluate the self-perceived impact of dizziness or vertigo due to BPPV on their daily lives.
The DHI is a 25-item questionnaire encompassing three domains: functional, physical, and emotional. The scores were summed, with a maximum score of 100; the higher the score, the greater the perceived handicap. Five items in the DHI were identified as particularly helpful in determining the likelihood of BPPV, making it a useful tool for both screening and monitoring patient’s progress [14]. The minimal clinically important difference (MCID) reported in the literature was observed when the total DHI score decreased from 18.05±9.91 on the 1st day to 9.54±9.94 at 30 days (P<0.001). This reduction was significantly correlated with scores on the 36-Item Short Form Health Survey scale [15].
Statistical analysis
The sample size was determined using power analysis calculations conducted with a web-based sample size calculator (http://www.stat.ubc.ca/~rollin/stats/ssize/b2.html). Based on the results of a similar study, the rates of vertigo resolution were 64% and 23% for SEM and BDE, respectively [9]. Using 80% power, a 5% marginal error (type I error α), and accounting for a 10% dropout rate, the calculated sample size was 25 patients in each treatment arm, resulting in a total sample size of 50.
Descriptive analysis was conducted to describe the basic characteristics of the recruited patients. Univariate analysis was performed to assess the association and to compare the outcome variables of SEM and BDE. For categorical variables, the association between two groups was evaluated using the chi-square test. The Mann-Whitney U test was used for continuous data. Mixed analysis of variance (ANOVA) was conducted to determine which therapy was more effective in achieving vertigo resolution, reducing vertigo intensity, and improving DHI scores over time (i.e., 1 and 6 months after the initiation of therapy). In this mixed ANOVA, the dependent variables were “vertigo resolution,” “vertigo intensity,” and “DHI scores”; the within-subjects factor was “time of assessment,” and the between-subjects factor was “type of therapy.” Any significant findings were further analyzed using post hoc tests to identify specific areas of difference.
To avoid bias, all patients were included in the analysis using an intention-to-treat approach. For missing observations, the last value carried forward method was used. Statistical significance was considered when the P-value was <0.05. Statistical analyses were performed using IBM SPSS ver. 23.0 (IBM Corp.).
Results
During the 1-year recruitment period of this study, 83 patients with posterior canal BPPV were referred for rehabilitation, 80% of whom visited a neurotology clinic. These patients were under follow-up but continued to experience recurrent or persistent symptoms despite initial treatment with the office Epley maneuver. After initial screening, 50 patients were recruited for this study (Figure 1).
A total of 45 patients were compliant with the 2-week home exercise program. A total of 24 patients complied more than 75% of the time, whereas 21 patients complied between 50% and 75% of the time. Five patients, on the other hand, were either noncompliant with therapy or lost to follow-up and were considered dropouts. However, data from all initially recruited patients were analyzed using an intention-to-treat approach, with all missing observations filled out using the last value carried forward method. No serious adverse events occurred after home-based exercise therapy, although some patients reported transient dizziness or nausea.
Table 1 lists the basic characteristics of the patients in the SEM and BDE groups, showing no statistically significant differences in demographic data between the two groups. The mean age was 56.6±14.7 years for the SEM group and 56.5±14.0 years for the BDE group. The mean duration of illness was 13.3±26.1 months for the SEM group and 10.4±24.3 months for the BDE group.
Data from all initially recruited patients were analyzed using an intention-to-treat approach, with all missing observations filled out using the last value carried forward method. In the univariate analysis (Table 2), at 1 month, 40% (n=10) of the patients in both the SEM and BDE groups achieved vertigo resolution (P=1.00). At 6 months, this increased to 48% (n=12) in each group (P=1.00). Repeated DHT was conducted at 1 month, revealing that 92% (n=23) of the patients in the SEM group and 84% (n=21) in the BDE group tested negative (P=0.38). The median baseline score for vertigo intensity in both groups was 4 (on a Likert scale of 1–5; P=0.785). At 1 month, a reduction in vertigo intensity was observed in both groups (P=0.903), and these scores remained consistent at 6 months. For the DHI score, a declining trend was noted in both groups at 1 and 6 months; however, there was no statistically significant difference between the two groups.
Mixed ANOVA was performed to compare the mean differences between the groups at different assessment times (Tables 3–7). When the type of therapy was ignored, there was no significant difference in vertigo resolution based on different assessment times (F(1,49)=2.70; P=0.107). However, significant differences were observed in vertigo intensity (F(1.6,78.4)=84.6; P<0.001) and DHI scores (F(1.7,85.1)=74.3; P<0.001). A post hoc test indicated that this significance was evident in all assessments. This means that, without comparing the type of therapy, there was a significant reduction in both vertigo intensity and DHI scores over time (Tables 3, 4).
However, when the assessment time was ignored, there were no significant differences in the vertigo resolution, vertigo intensity, or DHI scores between the SEM and BDE groups (Table 5). When both factors, that is the type of therapy and the time of assessment, were taken into consideration, no significant differences were observed in vertigo resolution, vertigo intensity, or DHI scores (Tables 6, 7).
Discussion
This study evaluated the effectiveness of two home-based exercise therapies, SEM and BDE, for the treatment of posterior canal BPPV. Although the original Epley maneuver is widely regarded as more effective than the BDE [1,2,11], the initial part of the Epley maneuver, which includes the Dix-Hallpike component, can be challenging for patients to perform at home without assistance. Therefore, SEM is gaining popularity among clinical practitioners for home-based prescriptions. This study is the first to compare the efficacy of SEM and BDE using a randomized controlled trial design employing multiple outcome measures, including vertigo resolution, conversion to a negative DHT, changes in vertigo intensity, and the DHI score.
Limitations
This study had several limitations. First, an important limitation is the potential for insufficient sample size. The sample size estimation was based on an assumed resolution rate of 80% for the SEM group and 20% for the BDE group, which may not adequately account for the variability in patient outcomes. Second, although most patients were considered compliant with the exercise program, their performance did not meet the expected standards, and compliance was measured subjectively based on patient reports.
Third, we did not quantify the frequency of vertigo symptoms, which would have provided additional information on the severity and progression of illness, especially in patients with recurrent vertigo. Our follow-up duration was limited to 6 months after the initiation of therapy, which may not be sufficient to capture recurrent episodes. Additionally, the assessments were conducted solely through clinical evaluation without the use of a Sensory Organization Test protocol or videonystagmography, which means that nystagmus could have been missed, potentially leading to false-negative DHT results. However, to improve the consistency of reporting, only one assessor (PI) was responsible for performing the DHT during the 1-month assessment.
Future studies should consider larger sample sizes to ensure more robust findings and capture additional variability across different patient subgroups. Recognizing that compliance with a home-based exercise program can be challenging, future studies should focus on improving compliance by integrating digital tools such as mobile applications or video tutorials to provide real-time guidance and feedback. Wearable devices or self-recorded video submissions can be used to objectively monitor patient performance and adherence. Additionally, with an adequate follow-up duration, the frequency of vertigo and dizziness episodes can be included as variables to monitor treatment progress and response. Exploring alternative therapies, such as hybrid maneuvers tailored to patient needs, may enhance the outcomes for those struggling with traditional SEM or BDE exercises, such as those with limited cervical range of motion. Other clinical assessments such as the Sensory Organization Test protocol and videonystagmography may be incorporated to provide more objective measures for future studies.
Generalizability
Among the 22 clinical trials included in the two Cochrane reviews on the Epley maneuver for BPPV and the modified Epley maneuver for BPPV, 11 mentioned the duration of illness [2,16]. Of these 11 trials, eight reported a duration of less than 3 months, two reported durations of 9 to 10 months, and one trial reported a duration of 24 months among their subjects. The duration of chronic illness may indicate persistent or recurrent BPPV.
In this study, the patients had a longer mean duration of BPPV, as the majority were referred from the neurotology clinic and continued to experience persistent or recurrent symptoms despite initial successful office-based treatment. Patients with persistent or recurrent symptoms are suitable candidates for home-based therapy trials as they allow for multiple treatment sessions [1]. This highlights the fact that despite undergoing a previous Epley maneuver upon initial diagnosis with positive DHT and being prescribed vestibular suppressant pharmacotherapy, patients can still suffer from residual symptoms of vertigo and dizziness that affect their activities of daily living.
It is also important to note that vestibular suppressant medications, such as antihistamines and benzodiazepines, lack evidence in the literature supporting their effectiveness as definitive primary treatments for BPPV. Furthermore, this may lead to potentially harmful sedation and cognitive side effects [1].
The resolution of BPPV does not depend solely on the conversion of positive to negative DHT. Therefore, the inclusion of other outcome measures, such as vertigo resolution, vertigo intensity, and DHI, will provide additional insights into the domains of impairment, activity, and participation.
Based on the results of this study, a structured home-based exercise program may be beneficial for patients with BPPV, particularly those with an initially high DHI score and those experiencing persistent or recurrent BPPV. The choice between SEM and BDE may depend on the clinician’s familiarity, patient convenience, or compliance. Our home-based exercise program was structured based on recommendations by Hain [12], which suggested performing three cycles just prior to bedtime, while also considering a short duration to enhance patient compliance. Although multiple therapy sessions are advantageous for patients with persistent symptoms, it was not possible to determine the optimal number of sessions needed [1].
Vertigo resolution
This study demonstrated that both exercises are effective home-based treatments for posterior canal BPPV. However, the vertigo resolution rate at 1 month was only 40% for patients in both treatment groups, although this rate increased slightly at 6 months. These changes were not statistically significant between the groups or across the assessment period.
A similar study compared the efficacy of SEM and BDE in 58 patients with posterior canal BPPV. Their results showed that 64% of the SEM group experienced a successful outcome (defined as vertigo resolution and the absence of positional nystagmus on DHT) compared with 23% in the BDE group (P<0.01) [9]. However, reassessment was conducted only 1 week after the initiation of therapy, whereas current guidelines recommend reassessment within 1 month of an initial observation or treatment period to confirm symptom resolution [1].
Conversion of Dix-Hallpike test
The conversion of positive DHT to negative DHT is often included as a secondary outcome measure of resolution of posterior canal BPPV in clinical trials because it is a more objective measure of improvement, although it may not reflect the patient’s perception of the condition [2]. In this study, most patients in both groups exhibited a conversion from positive to negative DHT at 1 month, but this was not statistically significant. A similar finding was noted in a study by Cohen and Sangi-Haghpeykar [11], who showed that DHT responses in both the SEM and BDE groups decreased significantly 1 week after the initiation of exercise, with further reductions at 3 and 6 months later. However, there were no significant differences between the two groups [11].
A previous systematic review noted that BDE was the least effective, compared to SEM, in terms of converting a positive to a negative DHT; however, this conclusion was based on a single randomized controlled trial, and because of the limited number of studies, the review was qualitative rather than a quantitative synthesis or meta-analysis [10]. Despite evidence suggesting that BDE is less effective than other PRMs, it remains one of the most commonly prescribed self-applied therapies with reported success in 95% of cases [12].
In a 2014 Cochrane review of the Epley maneuver (EM) for BPPV, the authors found that conversion to a negative DHT at 1 week and 1 month was statistically significant in the EM group compared with that in the BDE group. Nevertheless, the recurrence rate at 2 years was similar in both groups [2,17]. In the same review, it was also noted that there was no significant difference in the conversion of a positive to a negative DHT at 1 week post-treatment between EM and other maneuvers, such as the Semont liberatory maneuver or the Gans hybrid maneuver [2,18,19].
Vertigo intensity
Resolution of posterior canal BPPV is typically concluded when the patient reports vertigo resolution along with an objective measure indicating conversion of the DHT. However, considering that the average duration of a BPPV episode may be up to 2 weeks and that nearly half of the patients may report symptoms of imbalance between vertigo episodes that persist even after successful therapy measures of vertigo intensity and DHI were included to capture the overall consequences of BPPV [4]. A Cochrane review of vestibular rehabilitation for unilateral peripheral vestibular dysfunction in 2015 included the subjective outcomes of BPPV, such as the persistence of vertigo attacks and vertigo intensity, as these are directly related to health and functional status [20].
In this study, both the SEM and BDE groups experienced a significant reduction in vertigo intensity scores at 1 month, and these improvements were maintained at the 6-month assessment. However, there were no significant differences between the two groups. This finding aligns with that of Cohen and Sangi-Haghpeykar [11], who also showed significant improvement in vertigo intensity in both the SEM and BDE groups at 1 week, with scores plateauing by 6 months.
Changes in Dizziness Handicap Inventory score
Similar to the reduction in vertigo intensity, both the SEM and BDE groups showed a significant decrease in DHI scores at 1 month, with further improvement at 6 months. We believe that the reduction in vertigo intensity may explain the improvement in the total DHI score, though there was no significant resolution of vertigo. A lower DHI score indicates improved patient perception of functional, physical, and emotional well-being related to BPPV symptoms. In this study, DHI scores reached the MCID, with a reduction of 21.5 points for the SEM group (from 49.1±3.9 to 27.6±5.3) and a similar reduction for the BDE group (from 49.5±3.9 to 24.4±5.3) at 1 month from baseline. No significant differences were found between the two groups.
To our knowledge, only one other study, conducted by Cohen and Sangi-Haghpeykar [11], compared the impact of vertigo or dizziness on daily life between home-based SEM and BDE treatments. However, this study used a different outcome measure, the Vertigo Activities of Daily Living (VADL) Scale, to assess this effect. They reported a significant improvement in daily activities at 1-week post-treatment in both groups, but no further significant improvement at 3 or 6 months. Despite using a different outcome measure, the earlier study by Cohen et al. [21] found a moderate correlation between the VADL Scale score and the DHI total score (Spearman’s ρ=0.66, P<0.001).
Conclusions
Both SEM and BDE were effective in reducing the vertigo intensity and the impact of BPPV-related vertigo on daily life. However, neither exercise approach resulted in significant vertigo resolution at 1 month in patients with posterior canal BPPV. Therefore, clinicians may recommend either SEM or BDE as a home-based treatment for patients with unilateral posterior BPPV, based on their familiarity or the patient's preference.
Article Information
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
We sincerely thank all healthcare professionals and patients at Universiti Malaya Medical Center for their participation and contributions to this study.
Funding
This study was funded by the Postgraduate Research Fund of the Universiti Malaya, Kuala Lumpur.
Data availability
Data of this research are available from the corresponding author upon reasonable request.
Author contribution
Conceptualization: NHMH, MZAB, MM, CTY. Data curation: NHMH. Formal analysis: NHMH, NAM. Funding acquisition: MM, CTY. Investigation: NHMH, ARAR. Methodology: NHMH, MM, CTY. Project administration: NHMH, MM, NFHB. Resources: MM, CTY, MZAB. Software: NAM, NHMH. Supervision: MM, CTY, MZAB. Validation: NAM. Visualization: NFHB. Writing–original draft: NHMH, NAM, MM. Writing–review & editing: NFHB, MZAB, ARAR, MM, CTY. Final approval of the manuscript: all authors.
Figure 1
Flowchart of the study.
Table 1
The characteristics of patients with posterior canal BPPV in the study who were randomized into self-Epley maneuver and Brandt-Daroff exercise (n=50)
4. von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78:710-5.
9. Radtke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology 1999;53:1358-60.
10. Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther 2010;90:663-78.
13. Epley JM. The Canalith Repositioning Procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404.
14. Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otol Neurotol 2005;26:1027-33.
15. Lopez-Escamez JA, Gamiz MJ, Fernandez-Perez A, Gomez-Finana M, Sanchez-Canet I. Impact of treatment on health-related quality of life in patients with posterior canal benign paroxysmal positional vertigo. Otol Neurotol 2003;24:637-41.
17. Amor-Dorado JC, Barreira-Fernandez MP, Aran-Gonzalez I, Casariego-Vales E, Llorca J, Gonzalez-Gay MA. Particle repositioning maneuver versus Brandt-Daroff exercise for treatment of unilateral idiopathic BPPV of the posterior semicircular canal: a randomized prospective clinical trial with short- and long-term outcome. Otol Neurotol 2012;33:1401-7.
18. Dispenza F, Kulamarva G, De Stefano A. Comparison of repositioning maneuvers for benign paroxysmal positional vertigo of posterior semicircular canal: advantages of hybrid maneuver. Am J Otolaryngol 2012;33:528-32.
19. Mazoor T, Niazi SB. Efficacy of Semont manoeuvre versus Epley manoeuvre in benign paroxysmal positional vertigo. Pak Armed Forces Med J 2011;61:246-9.
Vertigo and DHI outcome variables within group when analyzed with main effect of time
Factor
Sum of squares
df
Mean square
F
P-value
Partial eta squared
Vertigo resolution
2.7
0.107
0.053
Within group
0.16
1
0.16
Error (time)
2.84
48
0.06
Total
3
49
Vertigo intensity
84.562
<0.001*
0.638
Within group
160.573
1.6
100.34
Error (time)
91.147
76.81
1.187
Total
251.72
78.414
DHI
15,843.99
74.264
<0.001*
0.607
Within group
27,529.97
1.738
-
Error (time)
17,793.71
83.4
-
Total
45,323.68
85.141
df were corrected using Greenhouse-Geisser estimates of sphericity (ɛ=0.80).
DHI, Dizziness Handicap Inventory; df, degrees of freedom.
*P<0.05 is considered statistically significant.
Post hoc test using Bonferroni correction to identify specific areas of significant difference
Comparison
MD±SE
P-value
95% CI
Vertigo intensity
Baseline vs. 1 mo
1.98±0.22
<0.001*
1.45–2.51
1 mo vs. 6 mo
0.38±0.14
0.025
0.04–0.72
Baseline vs. 6 mo
2.36±0.22
<0.001*
1.81–2.91
Dizziness Handicap Inventory
Baseline vs. 1 mo
23.28±2.88
<0.001*
16.15–30.42
1 mo vs. 6 mo
8.84±2.15
<0.001*
3.52–14.16
Baseline vs. 6 mo
32.12±3.06
<0.001*
24.53–39.71
MD, mean difference; SE, standard error; CI, confidence interval.
*P<0.05 is considered statistically significant.
Vertigo and DHI outcome variables within group when excluding the main effect of time
Factors
Sum of squares
df
Mean square
F
P-value
Partial eta squared
Vertigo resolution
0.000
1.000
0.000
Between group
0.000
1
0.000
Error
21.64
48
0.451
Total
21.64
49
Vertigo intensity
0.000
1.000
0.000
Between group
0.000
1
0.000
Error
193.333
48
4.028
Total
193.333
49
DHI
0.005
0.946
0.000
Between group
5.607
1
5.607
Error
57,323.893
48
1,194.248
Total
57,329.5
49
df were corrected using Greenhouse-Geisser estimates of sphericity (ε=0.80). P<0.05 is considered statistically significant.
DHI, Dizziness Handicap Inventory; df, degrees of freedom.
Interaction effect between time of assessment and home-based exercise program on outcome variables
Factor
Sum of squares
df
Mean square
F
P-value
Partial eta squared
Vertigo resolution
0.00
1.000
0.000
Between group
0.00
1
0.00
Within group
2.84
48
0.06
Total
2.84
49
Vertigo intensity
0.147
0.816
0.003
Between group
0.280
1.600
0.175
Within group
91.147
76.814
1.187
Total
91.427
78.414
Dizziness Handicap Inventory
0.436
0.620
0.009
Between group
161.653
1.738
93.034
Within group
17,793.707
83.403
213.346
Total
17,955.36
85.141
df were corrected using Greenhouse-Geisser estimates of sphericity (ε=0.80). P<0.05 is considered statistically significant.
df, degrees of freedom.
Estimated marginal means to show nature of interaction between time of assessment and exercise on the outcome variables
Measure
Exercise
Time (mo)
Mean±SD
95% CI
Vertigo resolution
SEM
1
1.600±0.100
1.399–1.801
6
1.520±0.102
1.315–1.725
BDE
1
1.600±0.100
1.399–1.801
6
1.520±0.102
1.315–1.725
Vertigo intensity
SEM
Baseline
3.520±0.224
3.070–3.970
1
1.640±0.319
0.999–2.281
6
1.240±0.292
0.652–1.828
BDE
Baseline
3.640±0.224
3.190–4.090
1
1.560±0.319
0.919–2.201
6
1.200±0.292
0.612–1.788
DHI
SEM
Baseline
49.080±3.913
41.212–56.948
1
27.640±5.255
17.075–38.205
6
16.360±4.436
7.442–25.278
BDE
Baseline
49.520±3.913
41.652–57.388
1
24.400±5.255
13.835–34.965
6
18.000±4.436
9.082–26.918
SD, standard deviation; CI, confidence interval; SEM, self-Epley maneuver; BDE, Brandt-Daroff exercise; DHI, Dizziness Handicap Inventory.
Table 1
The characteristics of patients with posterior canal BPPV in the study who were randomized into self-Epley maneuver and Brandt-Daroff exercise (n=50)
Values are presented as mean±standard deviation or number (%).
, Adi Rizal Abdul Rahman3, Mohd Zulkiflee Abu Bakar3,4
