Epley, Semont or Brandt-Daroff Exercises? Which should I choose?

13 comments

Posted on 5th May 2012 by Clearwater Clinical in BPPV - Diagnosis - Treatment - DizzyFIX

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Recently we were asked, “Which is best, the Epley, Semont or Brandt-Daroff for the treatment of BPPV?”.

Like many things the answer isn’t perfectly clear. However, many studies have been done on each one and results have been reported with each maneuver. I’ll address each one below.

1) Brandt-Daroff maneuver (this example is for the Right side):
This maneuver consists of sitting upright with your feet over the side of your bed, lying on your right side with your right ear against the bed, or with your head turned to the left. This first step brings the BPPV particles in your semicircular canals about 1/2 way around the bend of the canal (causing vertigo). Then sitting up. This allows the particles which have moved 1/2 way around to begin to fall back down the same way they came from. Then lying down on your left side with your left ear against the bed or turned a little to the right. This doesn’t really affect right sided particles as it puts the canal in a horizontal position but may stimulate symptoms in left sided BPPV if you have it in both ears.

What this maneuver does is create and stimulate the worst of vertigo in patients with BPPV but doesn’t actually treat the underlying cause. As such it is useful to habituate yourself to your vertigo. However, in light of the following two maneuvers I see no need to ever conduct this maneuver.

2) Semont maneuver.
There are two important differences between Semont and Brand-Daroff maneuvers. 1) Speed and 2) keeping your head pointing toward your left shoulder. Lets go over the example again for the right ear.

Start sitting then lie down on your right side. It is important to turn your head to the left and look up at the ceiling. This will stimulate BPPV. Stay there until the vertigo passes. Now QUICKLY sit up and lie on your left side but KEEP your head pointing over your left shoulder during the entire time. You should now be facing down to the ground. Do not turn your head. Wait there until any vertigo passes. Then sit up.

What has happened here is that the particles move into the bend of the semi-circular canals during the first positions, then when you quickly sit up they don’t have a chance to fall back. Finally, by looking towards the ground on the other side they fall out of the semi-circular canals all together.

Since this maneuver requires speed it can be difficult for the elderly. However, it requires less neck flexibility.

3) Epley maneuver.
This maneuver and the Semont maneuver share the beginning and ending head positions relative to gravity which is why they both work. (start on back with head facing ceiling, end on other side facing the floor). The Epley maneuver is not speed dependant as it doesn’t rely on momentum to carry the particles over the hump of the canal and down the other side.

The maneuver begins on the back with the head turned to the right. In the second step the person rolls their head to the left, then up onto the left shoulder and looks to the ground, then sits up.

Summary

There are a number of devices to help perform the Epley maneuver and most publications now recommend the Epley as the first choice of maneuvers unless there is some contraindication. To my mind there is no role for the Brandt-Daroff exercises unless both the Epley and the Semont maneuvers have failed.

13 Comments
  1. Clearwater Clinical says:

    Thanks for sharing your experience. Sleeping upright certainly avoids putting yourself in the stimulating position and thus avoids exacerbations. Many people are not able to sleep well sitting up, however. BPPV is by nature paroxysmal and will come and go. While the Semont and Epley have equal effectiveness when done by a professional they can be ineffective when done at home as it is difficult to be accurate when dizzy. You may find additional benefit by seeing a specialist of by using a home treatment device to ensure you perform the maneuvers correctly. BPPV is often recurrent so it may well come back – let us know how you do.

    25th March 2014 at 8:28 pm

  2. Inger Grape says:

    I want to add to my comment above. After the Semont maneuver cured me, I was symptom-free for a year. Then I had a dental procedure done where I was tilted almost backwards and towards my “bad” side; I could feel something that made me think, uh-oh. Surely enough, slowly the dizzy spells in the morning started coming back, and with it the total lack of sleep, with never-ending hot flashes during the night. It got every bit as bad as before, and I googled and found a modified Semont maneuver that involves lying down 3 min. on ea. side and no sitting up still for 10 min. afterwards.

    At first it helped a lot, but then it didn’t seem to so much. The last bad night was so bad that I was unable to even complete a Semont maneuver, as one or both of the positions was unbearably uncomfortable. Then the next day I noticed how well I slept in the passenger seat of our car on a long drive, so I spent the first part of that night sitting upright in my car, in a sleeping bag with headphones and a sleep mask. That was the road to my recovery. The next 3 nights I have started each night by sitting bolt upright on my sofa (I need to modify my neck collar for my short neck) and sleeping like that for an hour or two, then segueing into my bed, with a big berm of pillows to prop me up at a slant, which feels more comfortable (but it never actually helped before). Doing this, all of a sudden I was able to sleep undisturbed for 6 hours.

    After the first 3 nights of starting my sleep upright, I woke up feeling completely, 100% normal, for the 1st time in months. Today I’m on day 3 of feeling 100% normal, and I have not have had to do any positional maneuvers. The brief feeling of having the ground drop from under me every time I would bend my head forward is completely gone too. I am cautiously optimistic that I have found the key to my puzzle for now.

    25th March 2014 at 7:12 pm

  3. Clearwater Clinical says:

    Thanks for your questions. Yes there are different versions of the Epley. Some work, some don’t it really does depend on exactly what you do. The DizzyFIX device guides you through the standard maneuvers. You can also ready about why maneuvers sometimes don’t work here – http://clearwaterclinical.com/blog/2009/04/epley-maneuver-how-many-times-should-it-take.html

    It is safe to do the maneuver on an incline bench. Usually this is done for people who don’t have very good neck range of motion.

    Brandt-Daroff maneuvers for BPPV, in my view, are outdated as there are much better maneuvers which work. The key is to know what the diagnosis is. If you don’t have BPPV then no maneuvers will work.

    Thanks again for yor questions.

    18th February 2014 at 11:46 am

  4. Christopher says:

    I had BPPV about three years ago and was instantly cured by an ENT consultant. This time, having got BPPV after a heavy fall skiing, I did Brandt Daroff exercises for a week, as previously recommended. They achieved a little improvement but also a certain amount of nausea.

    Having read this article I switched to the Semont manoeuvre, which totally cured me in two days. I am 75 years of age.

    Thank you.

    7th January 2014 at 4:57 am

  5. Christy says:

    Thanks for the opportunity to get additional information about BPPV. I was diagnosed with left BPPV in early Nov 13. I had the Epley maneuver performed at my doctor’s office on a Friday followed by 72 hours of no head movement and sleeping semi-vertically. The following Friday my Doctor repeated the Epley maneuver followed by 48 hours of no head movement and sleeping semi-vertically. Unfortunately the procedures did not work so he recommended physical therapy. The physical therapist did a different version of Epley and also recommended the Brandt-Daroff maneuver at home which I have been performing for 10 days. I still have symptoms. PT is going to try the Epley maneuver next week on an incline bench. I am not comfortable with this decision and want to know if this is safe. Yesterday when I had the Epley performed my shoulders were extended beyond the table and caused quite a lot of pain in my neck. I guess my questions are: 1) Are the Brandt-Daroff maneuver exercises outdated? 2) Is it effective to do the Epley maneuver on an incline bench? Thank you so much for your time and information.

    18th December 2013 at 9:13 am

  6. Clearwater Clinical says:

    Log rolls work very well with horizontal canal BPPV. Unfortunately, the vertigo is worse and some people can vomit during the maneuver. This is quite unusual with p-BPPV.

    15th September 2013 at 9:13 pm

  7. Clearwater Clinical says:

    This is not correct. Medication will not impact the outcome of BPPV (for good or bad). The treatment is the Epley or the Semont maneuver. The Brandt Daroff exercises are simply designed for you to get used to the vertigo (why do this when you can get rid of it). It is possible that with Labyrinthitis (not with BPPV) medication may slow recovery by inhibiting your re-acclimation to your new state.

    15th September 2013 at 9:10 pm

  8. Clearwater Clinical says:

    People describe the sensation of “dizziness” quite differently. For most it is spinning but certainly some people do describe “waves” or other terms. The real indicator is the positional nature of it and the impact on the eyes (Nystagmus). Semont and Epley are essentially equivalent when done correctly.

    15th September 2013 at 9:07 pm

  9. Tanke says:

    for sure this Epley, Semont or Brandt-Daroff Exercises? Which should I choose? Why am I dizzy? Is it BPPV? is so excellent to read through

    24th August 2013 at 9:58 am

  10. Inger Grape says:

    The Semont maneuver, as shown by U of Michigan on YouTube, cured me. I did it every morning for about 2 weeks and the dizzy spells gradually subsided and then disappeared completely.

    Reclining was the position that got me in trouble; the “ear rocks” would severely disturb my balance sensors all night, not causing dizziness during the night but causing constant hot flashes and “restless-body syndrome,” a sensation of being tilted backwards (even when sleeping propped up), and complete lack of sleep. Then when I would get up, I’d experience a dozen or two dizzy spells till it subsided for the day, till the next morning. (Initially I thought the dizzy spells were brought on by the lack of sleep.)

    The Epley maneuver gave me 2 days of relief initially, which is how I could tell what it was (I diagnosed it, and the doc did not disagree). But then it didn’t seem to help much. One scary day I had a dizzy spell while driving, and that evening I tried the Semont maneuver, after one commentator said it helped him better than Epley.

    Significantly, the Semont maneuver started repairing my sleep from the first time I tried it, even before the dizzy spells disappeared. This was even when I did it starting from the wrong a side. (When I switched sides after a few days, it started working much better.) Now, several months later, I have had no more dizzy spells (and with them went the hot flashes and “restless-body syndrome”), the fear has almost left me, and my sleep is better than it has been in decades!

    Positional vertigo is epidemic (witness all the views, likes and comments on YouTube); as soon as I mention it, somebody is likely to say, “Oh, I have …” or “Oh, I know somebody ….” The approach of the medical community as a whole is deplorable (thank you for being the good guys!). Most doctors apparently are worse than no help! They’ll look everywhere else, scheduling MRIs, EKGs and all manner of other tests, then referrals and medications before they consider positional vertigo, the most common cause of dizzy spells! Is this purposeful? They are even trained to ask the wrong questions. There is no excuse for this. It is so common and easy to diagnose that instructional videos are all over YouTube, it was featured in an episode of the excellent British TV series “Doc Martin” (where the good doctor did the Epley maneuver, which all doctors should know to do) and I was able to diagnose it before my doctor! Among other things, positional vertigo does NOT have to have a spiraling component. The people I talked with had a similar experience of the dizzy spells that I had: No particular awareness of the room or me spinning or not; the feeling was more a sensation of complete chaos of awareness, where I would most certainly fall if I didn’t sit down, and even sitting down on a stool (or the toilet), I had to hold on for dear life. Sometimes when I would get up in the morning, the initial feeling wasn’t dizziness but rather as if I were a ship in high seas, with loose ballast rolling around–I was compelled to rock myself till “the ballast” settled.

    12th May 2013 at 10:46 am

  11. Cindy Chaney says:

    It is my understanding, based on what my doctor has explained, that the Brandt Daroff Exercise is used to create vertigo so that the brain is given multiple opportunities to detect imbalance and attempt to repair. If a person takes medication to stop the vertigo the brain is not given the opportunity to complete the repairing process.
    If the brain is given opportunities to detect the vertigo and attempts to repair – there is a chance that the vertigo will occur less and less naturally.
    If the brain is NOT given opportunities to detect the vertigo and attempt repair (when medication is used to stop vertigo and repair attempts) the patient will most likely have more and more occurrences of vertigo naturally.

    8th May 2013 at 11:00 am

  12. Dr.Sudiptarun Sen says:

    Iam a practising otolaryngologist. I titally agree with your approach. Excellent comparison. What is your experience with Log Roll in Horizontal canal BPPV?

    9th April 2013 at 9:37 pm

  13. DR.R.V.SURYANARAYANA says:

    DEAR SIR I AM APATIENT OF B P P V . SO FAR NO ONE GIVES ME SUCH A CLARIFICATION LIKE YOU WHICH IS EXCELLENT INSPITE OF ME BEING A M B B S GRADUATE .NO SPECIALIST BOTHERS TO EXPLAIN . I MIGHT HAVE VISITED MORE THAN 10 DOCTORS .MY PROBLEM IS FOR THE LAST 10 YEARS. BY WHICH I AM STILL SUFFERING .

    5th September 2012 at 1:32 am

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