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Group: Chelsea Townsend and Joanne Haggar Date submitted: November 24, 2014

Topic: Adult Vestibular Rehabilitation Specific question: Kevin is a 45 year-old male who enjoys surfing. He was recently diagnosed with benign
paroxysmal positional vertigo (BPPV), which is affecting his balance and ability to surf. Would adaptation through Cawthorne-Cooksey balance
exercises be more effective than habituation through Epleys maneuvers in improving his balance so he can enjoy surfing again?
Clinical Scenario: Kevin is a 45 year-old husband and father. When he is not working or spending time with his family, he enjoys surfing. He has
recently noticed that he becomes increasingly dizzy and light-headed throughout the day. He is clumsier than usual, often stumbling and running
into walls when turning corners. He has trouble tracking objects and increased light sensitivity. Occasionally, Kevin experiences ringing in his
ears, which makes it hard for him to focus on tasks. Kevin is worried that these vestibular abnormalities will hinder his ability to surf and care for
his children. Kevin is seen by a physician and learns he has benign paroxysmal positioning vertigo (BBPV). He is referred to an occupational
therapist to improve his balance and symptoms of vertigo through adaptation and habituation interventions.

Critically Appraised Topic Evidence Table

Author(s) (year)

Issue examined

Balance Rehabilitation by
Moving Platform and
Exercises in Patients with
Neuropathy or Vestibular

Efficacy of a Home-Based
Exercise Program on Benign
Paroxysmal Positional
Vertigo Compared with

Experience with Epleys

Manoeuvre and Vestibular
Habituation Training in
Benign Paroxysmal
Positional Vertigo

Nardone, A., Godi, M.,

Artuso, A., Schieppati, M.

Kulcu, D. G., Yanik, B.,

Boynukalin, S., Kurtais, Y.

Roa Castro, F. M., Duran de

Alba, L. M., Roa Castro, V.
H. (2008).

To determine the
effectiveness of a balance
treatment that uses both a
powered platform that the
patient stands on and

To determine the
effectiveness of a homebased exercises program
compared to the drug,
betahistine, in patients with

To determine the efficacy

of Epleys maneuver and
vestibular habituation
training in BPPV.

Effect of Epleys maneuver

on the quality of life of
paroxysmal positional
benign vertigo patients
Pereira, A.B., Santos, J.N.,
Volpe, F. M., (2010).

To determine the effect of

repositioning maneuvers
on the quality of life of
patients with BPPV.

specific physical exercises.


Design / Level of

The design used for this

study is a crossover trial.
The level of evidence is a
level 1.

The design used for this

study is a prospective,
randomized, controlled
study. The level of evidence
is a level 1.

The design used for this

study is a retrospective
review of patients with
BPPV. The level of evidence
is a level 4.


There were 33 participants

recruited for this study (9
men and 24 women). The
average age of participants
was 58.4 years. All of the
participants reported
having postural
unsteadiness caused by
either unilateral vestibular
deficit or neuropathy. 14
participants had vestibular
deficits and 19 participants
had peripheral neuropathy.
None of the participants
had received vestibular
treatment prior to the
study. Participants were
required to discontinue
using medication 2 weeks
before the study began.
Participants were divided
into 2 different groups. The
first group had 17
participants who

In this study, there were 39

participants (10 males and
29 females). The age of
participants ranged from 33
to 59. All of the participants
had been formerly
diagnosed with BPPV and
had previously received
repositioning maneuver
treatment before the study.
However, those who
received previous treatment
had to terminate inventions
3 months prior to the study.
Participants were divided
into two groups: exercise or

The study included 27

participants (9 men and 18
women) aged between 40
and 78 years, with an
average age of 56.7. The
participants had to meet
the following requirements
to participate in the study:
short and recurring
episode of vertigo caused
by changes in head
position, vertigo and
nystagmus detected during
the Dix-Hallpike maneuver,
and no alterations in the
central nervous system.

The design used for this

study is an observational
retrospective cohort
review of BPPV patients
and their chart records.
The level of evidence is a
level 4.
This study included 21
patients (18 female and 3
males) with a mean age of
53.2 years. 10 patients had
bilateral BPPV and 11 had
unilateral BPPV. The
sample consisted of the
charts of BPPV patients
being treated in the
vestibular rehabilitation
unit of a speech therapy
clinic. Participants had to
agree to answer the
dizziness handicap
inventory (DHI) and signed
an informed consent form.

Methods /
Intervention /
Measurement tools

underwent powered
platform exercises and
then exercise treatment,
while the other group had
16 participants and
underwent the same
treatment in reverse order.
The balance exercise
intervention was
performed in the hospital
gymnasium, while the
powered platform
intervention was
performed in the posture
and movement laboratory
at the same hospital. Both
treatments administered
by a physical therapist. For
both treatment groups,
patients completed 10
sessions total; 2 thirtyminute sessions a day for 5
sequential days.
exercises were used with
patients with vestibular
deficits, and Modified
Frenkel exercises were
used with patients with
neuropathy. Powered
platform treatment was
used for both groups. For
this particular treatment,
patients were required to

Patients were randomly

assigned to one of the two
treatment groups before
baseline assessments were
performed. The medication
group used betahistine to
increase circulation in the
inner ear and improve
vestibular functioning. Those
receiving betahistine were
prescribed 8 mg, three times
a day, for 1 month. The
exercise group used a series
of head and eye movements,
known as CawthorneCooksey exercises. These
patients performed the
exercises two times with
hospital supervision to
assure exercises were done
properly before being able to
start the home exercise
program. Exercises were
then performed at home for
six times a day for 4 weeks.
The frequency and duration
of the exercises were to be

Epleys maneuvers were

carried out in 17 patients, 6
males and 11 females,
whose ages ranged
between 40 and 78 years.
The Epleys maneuver was
performed as follows: the
patient is taken to the
Hallpike position towards
the side of the affected
ear, the head is turned 90
degrees towards the
opposite ear, and the
patient is laid on the
opposite side with their
head in prone position, and
then transferred to sitting
position with the head still
turned. After maneuvers
were completed, all
participants were required
to wear a soft collar brace
for 48 hours and were told
to sleep in the semi-Fowler
position. From the third to
seventh day, they were
instructed to sleep in the

A sample of patients from

a vestibular rehabilitation
unit of a speech therapy
clinic were asked to
complete the DHI
assessment before and
after treatment. All
patients underwent
vestibular rehabilitation
through Epleys maneuvers
at the facility. Epleys
maneuver consists of
repositioning the head in
different directions. The
DHI assesses the impact of
dizziness on the quality of
life of patients. It also
assesses the selfperceptions of the
incapacitating effects of
dizziness. The DHI consists
of 25 questions; 7
questions relate to physical
aspects of quality of life, 9
questions assess the
emotional aspects, and 9
questions measure the

stand on the powered

platform with their eyes
open and eyes closed in
different trials. There were
8 trials using this method
with a rest period of less
than 1 minute. The
following evaluations were
used: stabilometry,
subjective evaluation of
stability, clinical evaluation
of balance and gait, and
assessment of balancing
behavior during sinusoidal
translations of the
supporting surface. Each
evaluation was performed
before the first treatment,
after the first treatment,
and after the second
treatment. The evaluations
were conducted by a nonblinded physical therapist.
To test balance through
the stabilometry
assessment, body sway
was measured using a
dynamometric powered
platform. Patients were
asked to measure their
own performance based on
the stabilometric trial.
Balance and gait were
evaluated using the Tinetti

done as tolerated by each

participant. Participants
were to keep a log of
symptoms and effects of the
treatment program. After
the treatment period, both
groups were observed for a
month without intervention.
The assessments used to
measure symptoms were the
Vertigo, Dizziness, Imbalance
Questionnaire (VDI) and the
Vertigo Symptom Scale
(VSS). These questionnaires
were given at the beginning
of the study and during the
second, fourth, and eighth
weeks thereafter. The MannWhitney U test was used to
determine difference
between the two

decubitus position with

their unaffected ear
downwards. On the
seventh day, each patient
was assessed and the DixHallpike maneuver was
performed. The remaining
10 participants (7 woman
and 3 men), age 40-69,
received vestibular
habituation exercises.
These exercises included:
postural control, sitting
and standing exercises,
head-eye coordination
exercises, and habituation
to vertigo exercises. These
exercise were performed
twice daily for 4 weeks and
patients were evaluated
after 48 hours, 7 days, and
monthly until the third
month. Data was
configured using STATA 9
program and the
therapeutic modalities
were compared using
Fishers exact test.

functional aspects. These

questions can have a
response of yes, no, or
sometimes. The
maximum score for the
physical aspects is 28, the
maximum score for the
emotional aspects is 36,
and the maximum score for
the functional aspect is 36.
Higher scores are
equivalent to a decrease in
quality of life. The Minitab
software version 13.01 was
used to generate the

Threats to internal

Outcomes / findings

Mobility assessment. 12
patients with vestibular
deficits and 10 with
neuropathy were
evaluated with the
assessment of balance
behavior during sinusoidal
translation of the
supporting surface.
Time constraints for
treatments may have
limited optimal outcomes.

The results show that all

interventions increased
balance regardless of the
order it was administered;
however, patients with
vestibular disorders had
greater outcomes. Greater
improvements were seen
after the second treatment
compared to after the first.

Only 70% of participants

from the exercise group
completed their treatment
logs, which makes the
documentation of symptoms
questionable. The same
situation occurred with the
medication group, with only
55% of participants
completing their logs.

The study is not well

structured and does not
specify the treatment each
patient received. It is not
clear how or when the DixHallpike test was used.
These factors lead us to
believe that internal
validity is threatened.

The results show that by the

fourth week the VDI and VSS
scores decreased in the
exercise group. By the
second week, the VDI and
VSS scores decreased in the
medication group. The
exercise group showed
beneficial outcomes in 46%
of the participants within a
week and 84% of
participants within the
eighth week.

Epleys maneuver was

successful in 100% of the
participants. 82%
responded in the first 7
days after the first
maneuver, however,
relapses occurred in 17.6%.
Vestibular habituation
training was successful in
90% of participants within
the first month, but the
success rate dropped to
80% in the second and

The sample size of this

study was relevantly small
compared to similar
studies testing the effect of
BPPV on quality of life.
Also, there was no control
group to compare the data.
Because of these threats,
the researchers note that
the results should only be
taken as a suggestion.
The DHI results for pretreatment physical scores
were the highest, followed
by the functional aspects
and then emotional
aspects. There was a
statistically significant
difference in the effects of
dizziness on quality of life
in all three aspects. The
results show a positive
effect of Epleys maneuver
on the quality of life in


The crossover design

doesnt indicate which
intervention is causing a
greater change in the
desired outcome. Also, a 5day treatment plan is not
sufficient time to produce
significant results.


Both treatment
interventions provided the
desired outcome of
improved balance, which
shows confidence in the

Clinical Implications

Both Cawthorne-Cooksey
exercises and powered
platform activities can be
used as occupational
therapy intervention for
improving balance in
individuals with vestibular

One limitation of this study is

that the researchers do not
know the long-term results
past 8 weeks of treatment.
Future studies should asses
the long-term effects of
vertigo rehabilitation.
Another limitation is that
some participants
discontinued the exercise
program after the fourth
The researchers conducted
additional neurological
examinations and
electronystagmography tests
to assure the patients
diagnoses of BPPV, and to
rule out any other conditions
that could affect the study.
Home-based exercise
programs using CawthorneCooksey exercises can be
used to lessen the symptoms
of BPPV. Medication can also
be used as treatment to
reduce the symptoms of

third months. Epleys

maneuver is a favored
treatment option because
it required less time for
satisfactory results
compared to vestibular
habituation exercises.
The sample size for this
study is too small to be
able to generalize the
results to a larger
population of people with

patients with BPPV.

This study seems to have

more faults than strengths.

The DHI assessment was

administered before and
after the Epleys maneuver
treatment, which shows
the statistical significance
of the treatment.

Epleys maneuver is an
effective intervention that
can be administered by
occupational therapists
with patients who have
BPPV and other vestibular

The DHI assessment is a

valuable tool to use in the
clinic to evaluate
conventional vestibular
rehabilitation. Also, Epleys
maneuver treatment can
be linked to greater quality

The relatively small sample

size and lack of a control
group are limitations to the
study. Because of these
limitations, the results
cannot be generalized to
the population at large.
Remission may occur after
weeks of therapy, which is
another limitation of this

Social validity


BPPV, but is not as effective

as exercise.

This study has social

validity because these
interventions can easily be
used by therapists or in
home based exercise
programs to treat
vestibular disorders.

This study has social validity

because Cawthorne-Cooksey
exercises are shown to
promote visual stability
during head movements and
can easily be performed at a
clinic or at home.

This study has social

validity because Epleys
maneuver is a known
treatment option for
people with vestibular
disorders. However, in this
study, the poor internal
validity does not showcase
the beneficial outcomes of
this intervention.

of life for patients with

dizziness and related
vestibular disorders.
This study has social
validity because Epleys
maneuvers had a positive
impact on the physical,
functional, and emotional
aspects of quality of life.

Gaps in the literature:

Yes, there are gaps in the literature because there are no studies directly comparing Cawthorne-Cooksey exercises to Epleys maneuver in
reducing symptoms of Benign Paroxysmal Positional Vertigo. The research we found stated the benefits of both treatment options (CawthorneCooksey exercises and Epleys maneuver), but compared them to unrelated interventions that did not relate to the PICO question. Based on the
gaps in literature, more research needs to be done in order to make an evidence based judgment as to which intervention is more effective.
Clinical summary for occupational therapy practice:
Based on our findings, both Cawthorne-Cooksey exercises and Epleys maneuver are effective interventions for individuals with Benign
Paroxysmal Positional Vertigo, but we cannot conclude which treatment option is more beneficial. We did, however, conclude that Epleys
maneuver could be used by an occupational therapist in the clinic as a first option. Then, the occupational therapist could educate the client on
how to perform Cawthorne-Cooksey exercises on his or her own as a home-based exercise program.
Attach documentation of search strategies:
Before searching databases through TWU library, we read through a few different websites to get background information needed to dig deeper
into the topic. We found the Vestibular Disorders Association website very helpful in trying to understand our topic. Two of the articles we found
using the PubMed database by searching key words such as BPPV and Epleys maneuver, vertigo and habituation, and BPPV and

habituation therapy. The other two articles we found using the CINAHL Complete database and the MEDLINE with full text database. For these
two sites, we used key words such as BPPV and Cawthorne-Cooksey exercises, BPPV and balance exercises, and BPPV and balance
rehabilitation. We read several abstracts to sort through articles, which led us to more relevant information and the articles we used for this


Kulcu, D.G., Yanik, B., Boynukalin, S., Kurtais, Y. (2008). Efficacy of a home-based exercise program on benign paroxysmal positional
vertigo compared with betahistine. Journal of Otolaryngology-Head & Neck Surgery. 37(3):373-379.

Nardone, A. Godi, M. Artuso, A., Schieppati, M. (2010). Balance rehabilitation by moving platform and exercises in patients with
neuropathy or vestibular deficit. Arch Phys Med Rehabil. 91:1869-77.

Pereira, A.B., Santos, J.N., Volpe, F.M. (2010). Effect of Epleys Maneuver on the quality of life of paroxismal positional benign vertigo
patients. Braz J Otorhinolaryngol. 76(6):704-8.

Roa Castro, F.M., Duran de Alba, L.M., Roa Castro, V.H. (2008). Experience with Epleys manoeuvre and vestibular habituation
training in benign paroxysmal positioning vertigo. Acta Otorrinolaringol Esp .59(3):91-5.