Semont-plus maneuver bests EM self-maneuver in shortening recovery days in posterior canal BPPV

New research revealed that Semont-plus maneuver (SM-plus) is superior over Epley maneuver (EM) for treatment of posterior canal benign paroxysmal positional vertigo (pcBPPV) canalolithiasis. The study results were published in the journal JAMA Neurology.

Benign paroxysmal positional vertigo (BPPV) is characterized by recurrent brief episodes of spinning positional vertigo, provoked by lying down or turning over in the supine position. Posterior canal is affected in majority of the cases hence called the posterior canal BPPV (pcBPPV) canalolithiasis. Epley repositioning maneuver (EM) and the Semont maneuver (SM) are the therapies of choice for treating pcBPPV. These can be applied as self maneuvers. Recently using a biophysical model and computer simulations, SM-plus was developed where the patient is moved by at least 240° toward the nonaffected side yielding better results. Hence researchers conducted a prospective randomized clinical trial to compare the effectiveness of the Semont-plus maneuver (SM-plus) and the Epley maneuver (EM) for treatment of posterior canal benign paroxysmal positional vertigo (pcBPPV) canalolithiasis.

The trial was performed at 3 national referral centers (in Munich, Germany; Siena, Italy; and Bruges, Belgium) over 2 years, with a follow-up to 4 weeks after the initial examination. Recruitment took place from June 1, 2020, until March 10, 2022. Nearly 253 eligible patients were randomly selected during routine outpatient care after being referred to 1 of the 3 centers. Among them 56 patients were excluded and 2 declined to participate, with 195 participants included in the final analysis. As per the prespecified protocol, patients were randomized to SM-plus or the EM group where they received 1 initial maneuver from a physician, then subsequently performed self-maneuvers at home 3 times in the morning, 3 times at noon, and 3 times in the evening.

Patients were asked to document if they could provoke positional vertigo every morning. The primary end point was the number of days until no positional vertigo could be induced on 3 consecutive mornings. The secondary end point was the effect of the single maneuver performed by the physician.

Key findings:

• Of the 195 participants included in the analysis, the mean (SD) age was 62.6 (13.9) years, and 125 (64.1%) were women.
• The mean (SD) time until no positional vertigo attacks could be induced in the SM-plus group was 2.0 (1.6) days whereas in the EM group it was 3.3 (3.6) days.
• For the secondary end point (effect of a single maneuver), no significant difference was detected (67 of 98 [68.4%] vs 61 of 97 [62.9%]).
• There were no serious adverse events detected with both maneuvers.
• Nineteen patients (19.6%) in the EM group and 24 (24.5%) in the SM-plus group experienced relevant nausea.

Thus, SM-plus was found to be more effective than the EM in terms of days until recovery. Reproducible results were found in terms of the time until patients become free of symptoms.

Further reading: Strupp M, Mandala M, Vinck A, et al. The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study. JAMA Neurol. Published online June 26, 2023. doi:10.1001/jamaneurol.2023.1408