Semont-Plus Superior to Epley Maneuver to Resolve Posterior Canal BPPV Symptoms

Semont-plus maneuver is superior to the Epley maneuver for patients with posterior canal benign paroxysmal positional vertigo canalolithiasis.

Patients with posterior canal benign paroxysmal positional vertigo (BPPV) reported faster resolution of symptoms after treatment with the Semont-plus maneuver compared with the Epley maneuver, according to study findings published in JAMA Neurology.

The Epley maneuver involves rotating and extending the head after the patient is already supine. The Semont-plus maneuver requires rotation of the patient’s head 45 degrees to the unaffected side followed by a 90 degree turn toward the affected side achieved by side lying. After 1-minute, the patient lies on the unaffected side for another minute followed by sitting upright and maintaining position for 1-minute.

Researchers in Germany, Italy, and Belgium conducted a prospective, multicenter, randomized controlled trial (Comparison of EM and SM+ Maneuvers in Patients With BPPV; Identifier: NCT05853328) from June 1, 2020 to March 10, 2022 to compare the efficacy of the Semont-plus and Epley maneuvers for posterior canal BPPV.

Following a comprehensive neurologic assessment, the researchers randomly divided 214 individuals diagnosed with posterior canal BPPV canalolithiasis into 2 treatment groups. By the end of the study, 19 patients either were lost to follow-up, discontinued treatment, or performed the wrong maneuver, leaving 97 individuals in the Epley maneuver group and 98 in the Semont-plus maneuver group.

In patients with pcBPPV canalolithiasis, the SM-plus maneuver is superior to the EM in terms of the time until no positional vertigo could be induced by the patient.

The final 195 individuals comprised 125 women and 70 men with a mean age of 62.6. Approximately 58 of the 97 (59.8%) patients in the Epley group and 61 of 98 (62.2%) in the Semont-plus group demonstrated right sided BPPV.

After confirmation of BPPV diagnosis, each participant received 1 single treatment from a trained physician. Following this treatment, the physician instructed each participant to perform self-maneuvers at home 3 times in the morning, 3 times at noon, and 3 times in the evening.

Every morning, the patients recorded whether change in position could provoke symptoms of vertigo. The researchers analyzed the number of days until absence of positional vertigo for 3 consecutive mornings. Additionally, the researchers studied the efficacy of each maneuver based on absence of vertigo or nystagmus following a single treatment provided by the physician.

Individuals in the Semont-plus maneuver treatment group reported an average of 2 days (95% CI, 1.64-2.28 days) for BPPV symptom resolution, whereas those in the Epley maneuver treatment group reported an average of 3.3 days (95% CI, 2.62-4.06 days) for BPPV symptom resolution (difference between treatment groups: 1.3 days; P <.01).

A single physician-provided treatment resolved both subjective and objective BPPV symptoms in 67 of 98 (68.4%) individuals in the Semont-plus maneuver group and 61 of 97 (62.9%) in the Epley maneuver group. This resulted in no significant difference in the single-treatment efficacy of the maneuvers when provided by experienced physicians (difference between groups: 5.5%; P =.42).

Serious adverse events did not occur in either treatment group with the most relevant treatment-related symptom of nausea occurring in 19.6% of participants in the Epley group and 24.5% of participants in the Semont-plus group.

“This prospective randomized study provides evidence that, in patients with pc [posterior canal] BPPV canalolithiasis, the SM [Semont-plus]-plus maneuver is superior to the EM [Epley maneuver] in terms of the time until no positional vertigo could be induced by the patient,” the researchers wrote. “Hence, the SM-plus can be recommended in clinical practice.”

Study limitations included lack of control over how well the patients performed the self-maneuvers at home, determination of primary outcomes based on patient self-report, and lack of comparing maneuver efficacy when repeatedly performed exclusively by the therapist.

Disclosures: Several study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see original source for full list of disclosures.


Strupp M, Mandala M, Vinck AS, 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