What is canalith repositioning?
Canalith repositioning is a set of guided head and body movements that move loose calcium crystals (otoconia) out of an inner ear canal and back to the utricle, where they stop causing vertigo. It is the first-line treatment for benign paroxysmal positional vertigo (BPPV) in the clinical practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery.
BPPV causes brief, intense spinning when you roll over in bed, look up or bend down. A maneuver only works when it matches the ear and canal involved, which is why we test first. A Cochrane review found the Epley maneuver safe and effective for posterior canal BPPV.
Which maneuver treats which type of BPPV?
| Canal involved | How we find it | Maneuvers we use |
|---|---|---|
| Posterior canal (most common) | Dix-Hallpike test | Epley maneuver (canalith repositioning procedure) or Semont maneuver |
| Horizontal (lateral) canal | Supine roll test | BBQ (Lempert) roll or Gufoni maneuver, chosen by the direction of the eye movements |
| Anterior canal (rare) | Dix-Hallpike or deep head-hanging test | Deep head-hanging (Yacovino) maneuver |
| Crystals stuck to the cupula (cupulolithiasis) | Eye movements that last as long as the position is held | Liberatory maneuvers such as the Semont or Gufoni, often over more than one visit |
Read more about horizontal versus posterior canal BPPV and anterior and multi-canal BPPV.
How we choose the right maneuver in Cumming and Alpharetta
At North Atlanta Vertigo & Physical Therapy, serving Cumming and Alpharetta, GA, Dr. Manan Patel, PT, DPT, a Certified Vestibular Specialist, and our physical therapists test before we treat. With infrared video goggles, we watch your eye movements (nystagmus) during positional tests. Their direction and timing show which ear and which canal is involved, and whether the crystals are moving freely in the canal (canalithiasis) or stuck to the cupula (cupulolithiasis).
- Dix-Hallpike and supine roll tests, recorded with infrared video goggles
- A neck and back screen, so the maneuver can be adapted if your movement is limited
- A check for eye movement patterns that do not fit BPPV, which we refer for medical evaluation
Treatment often starts at the first visit. We re-test after each maneuver to confirm the crystals have moved, and every visit is 60 minutes, one-on-one.
What to expect during and after treatment
A maneuver takes a few minutes. You move through a series of positions, each held for about 30 seconds to a minute or until the spinning settles. Brief vertigo during the maneuver is common and is a sign the crystals are moving.
The BPPV guideline advises against routine movement or sleeping restrictions after repositioning for posterior canal BPPV, so most people go about their day normally. Some people feel slightly off-balance for a few days afterward. If that lingers, short-term balance exercises help, and we re-test at your next visit. Read about dizziness that lingers after BPPV treatment.
BPPV can come back, sometimes months or years later. If it does, repeat treatment usually works just as well. See why BPPV comes back.
Who may need a modified approach?
Standard maneuvers move the head and neck into rotation and extension. We adapt them, or use alternatives such as the Semont or Gans maneuver, if you have:
- Neck problems, recent neck or back surgery, or limited neck movement
- Significant back or hip pain, or difficulty lying down
- A history of blood vessel problems in the neck, which we discuss with your physician before positional testing
- A recent head injury, where we also screen for concussion
Self-treatment at home is not recommended until the affected ear and canal are known, because the wrong maneuver can move crystals into another canal. Read about the risks of home Epley videos.
Frequently asked questions about canalith repositioning
Does the Epley maneuver hurt?
No. It can bring on a short burst of spinning, and sometimes nausea, while the crystals move, but it is not painful. We go at your pace and adapt the positions if your neck or back is sore.
How quickly does canalith repositioning work?
Many people with typical posterior canal BPPV feel better after one to three treatments. Horizontal canal, multi-canal or recurring BPPV can take a few more visits.
Can I do the Epley maneuver at home?
Once we know which ear and canal are involved, we may teach you a home version. Without that information, a home maneuver can treat the wrong side or move crystals into another canal.
Do I need medication for BPPV?
Usually not. The BPPV clinical practice guideline advises against routinely treating BPPV with vestibular suppressant medicines such as meclizine, because repositioning treats the cause.
Related conditions and guides
- BPPV (positional vertigo)Symptoms, testing and treatment for inner ear crystal vertigo.
- Vestibular rehabilitationExercise-based therapy for dizziness that lingers after BPPV or has another cause.
- The Epley maneuver: when it works, and why the side mattersHow canalith repositioning works, why home attempts fail, and what to expect afterward.4 min read · Patients
- What is BPPV? Are loose inner ear crystals causing your spinning?Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Tiny calcium carbonate crystals…2 min read · Patient question
References
- Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology–Head and Neck Surgery. 2017.
- Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews. 2014.
- von Brevern M, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. Journal of Vestibular Research. 2015.
- Yacovino DA, Hain TC, Gualtieri F. New therapeutic maneuver for anterior canal benign paroxysmal positional vertigo. Journal of Neurology. 2009.
Where to get treated
Book at either clinic. Same phone number, same team, same 60-minute visits.
Cumming clinic
Off GA-400 Exit 13 on Peachtree Parkway
Cumming, GA 30041
Alpharetta clinic
Inside Georgia Brain & Spine Physical Therapy
Alpharetta, GA 30022
Also serving Johns Creek, Milton, Roswell, Suwanee and nearby communities.
