Treatment maneuvers for benign paroxysmal positional vertigo (BPPV)

By Marcello Cherchi, MD PhD

The underlying mechanism of benign paroxysmal positional vertigo (BPPV) is the presence of loose particles (variously called “otoliths” or “otoconia”) in one or more of the semicircular canals of the labyrinth. As this is essentially a “mechanical” problem, its treatment is correspondingly mechanical, and appropriately targeted vestibular rehabilitation therapy by a physical therapist is firmly supported as the standard of care.

The goal of the maneuvers used in the treatment of BPPV is to exploit gravity by moving the patient’s head through a series of positions in order to guide the loose particles out of the involved semicircular canal, into the utricle (where the particles have a much better chance of getting resorbed). Since the canals are arranged in different orientations, the specific maneuver chosen depends upon knowledge of which canal is involved (sometimes referred to as “localizing” the affected canal and side).

There are several factors that can make the treatment of BPPV more complex.

• Difficulty in performing a maneuver. Some maneuvers are harder to perform than others, both for patients and for clinicians.
• Simultaneous involvement of multiple canals. In some circumstances a patient may have multiple canals involved simultaneously. In this case, some physical therapists may elect to focus first on one canal (typically the one that is more prominently involved) and make sure its BPPV is resolved before moving on to another canal. Other therapists may be comfortable treating multiple canals simultaneously.
• Uncertainty of which canal is involved. In some circumstances it may not be entirely clear which canal is involved. For example, it is often possible to diagnose lateral canal BPPV, but difficult to identify which side is involved.
• Risk of canal conversion is a recognized complication. One of the risks of treating BPPV in a given canal is that, even when doing the appropriate treatment maneuver correctly, a patient may undergo a “canal conversion,” which simply means that some or all of the loose particles have exited one canal and entered a different canal. Since the mere feeling or sensation of disequilibrium does not in itself localize the involved canal, the best way of recognizing that a canal conversion has taken place is for an examiner to observe the patient’s eye movements during treatment.
• Patient comfort. The majority of patients tolerate vestibular rehabilitation therapy for BPPV quite well. However, some patients are very averse (at least initially) to the sensation of disequilibrium that a treatment maneuver provokes.
• Patient’s physical limitations. Most of the treatment maneuvers for BPPV involve some movement of the head with respect to the shoulders — which entails neck movements such as rotation, anterior-posterior flexion, and lateral flexion. For patients with significant limitations in range of motion (such as severe arthritic changes of the neck, or a history of cervical vertebral fusions), the maneuver may need to be modified to accommodate the limitation.  Vestibular physical therapists are skilled in adjusting maneuvers in this way (Cox and Frith 2025).
• Patient competence. In many cases of BPPV a treatment maneuver may generally be easy to do, and the physical therapist may feel comfortable assigning treatment exercises for a patient to do at home on their own (in between appointments with the physical therapist). However, if a physical therapist suspects that a patient would have difficulty performing the maneuver (such as when a patient is very apprehensive, or a patient’s ability to follow instructions is impaired by dementia), then the therapist may recommend that the treatment be performed only under his or her direct supervision.

Because of these factors, we generally recommend that, at least initially, a patient’s treatment of BPPV should be supervised by a vestibular physical therapist, and we suggest that a patient identify vestibular physical therapists who can help them, ideally therapists who are relatively close (geographically) with favorable schedule availability.

However, in some circumstances there may simply not be a vestibular physical therapist available; or a patient has already had BPPV and is comfortable trying to treat it on their own, or needs a “refresher” on the maneuver; or a therapist needs a quick reminder of how to do a particular maneuver. For these circumstances we provide guides to resources regarding particular maneuvers. Remember that the choice of an appropriate maneuver will depend on the diagnosis, and specifically on the localization of BPPV (which canal is affected). Simply trying random maneuvers is tantamount to treating blindly, and we would discourage such an approach.

Given that the maneuvers involve a series of movements, our experience is that the majority of people (both patients and practitioners) find it easier to absorb this information through videos rather than through static pictures (such as diagrams).

Canal	Patient’s left side	Bilateral (or side unknown)	Patient’s right side
Posterior (inferior) canal	Posterior canal, left side Epley maneuver for left posterior canal Semont maneuver for left posterior canal Semont plus maneuver for left posterior canal Foster maneuver for left posterior canal Gans maneuver for left posterior canal Modified Epley maneuver for left posterior canal	Posterior canal, bilateral or side unknown Brandt-Daroff maneuver for bilateral (or unknown) posterior canals	Posterior canal, right side Epley maneuver for right posterior canal Semont maneuver for right posterior canal Semont plus maneuver for right posterior canal Foster maneuver for right posterior canal Gans maneuver for right posterior canal Modified Epley maneuver for right posterior canal
Lateral (horizontal) canal (whether geotropic or apogeotropic)	Lateral canal, left side Lempert roll (logroll, BBQ roll) for left lateral canal Vannucchi-Asprella maneuver, left side	Lateral canal, bilateral or side unknown Kurtzer hybrid maneuver for bilateral (or unknown) lateral canals	Lateral canal, right side Lempert roll (logroll, BBQ roll) for right lateral canal Vannucchi-Asprella maneuver, right side
Lateral (horizontal) canal, geotropic variant	Lateral canal, geotropic, left side Gufoni/Appiani maneuver for left lateral canal, geotropic Modified Zuma maneuver, left lateral canal, geotropic		Lateral canal, geotropic, right side Gufoni/Appiani maneuver for right lateral canal, geotropic Modified Zuma maneuver, right lateral canal, geotropic
Lateral (horizontal) canal, apogeotropic variant	Lateral canal, apogeotropic, left side Gufoni/Appiani maneuver for left lateral canal, apogeotropic variant Zuma maneuver for left lateral canal, apogeotropic variant		Lateral canal, apogeotropic, right side Gufoni/Appiani maneuver for right lateral canal, apogeotropic variant Zuma maneuver for right lateral canal, apogeotropic variant
Superior (anterior) canal	Anterior canal, left side Modified (reverse) Semont maneuver for left anterior canal Kim maneuver for left anterior canal Reverse Epley maneuver for left anterior canal Rahko maneuver, left anterior canal	Anterior canal, bilateral or side unknown Yacovino maneuver for bilateral (or unknown) anterior canals Casani maneuver for bilateral (or unknown) anterior canals Crevits prolonged forced positioning procedure	Anterior canal, right side Modified (reverse) Semont maneuver for right anterior canal Kim maneuver for right anterior canal Reverse Epley maneuver for right anterior canal Rahko maneuver, right anterior canal

As mentioned earlier, in order to select an appropriately targeted canalith repositioning maneuver, it is generally necessary to know which canal (or canals) is affected by benign paroxysmal positional vertigo (BPPV).

Some well-studied maneuvers may treat more than one canal.  For example:

• The Brandt-Daroff maneuver can treat bilateral posterior canal BPPV (or treat posterior canal BPPV when the side is unknown).
• The Yacovino maneuver can treat bilateral anterior canal BPPV (or treat anterior canal BPPV when the side is unknown).

Less well-studied maneuvers for treating unilateral anterior canal BPPV when the affected side is known include:

• The Garaycochea maneuver (Garaycochea et al. 2022).

Less well-studied maneuvers for treating unilateral lateral canal BPPV when the affected side is known include:

• The Vannucchi-Asprella maneuver proposed by Paolo Vannucchi, Beatrice Gianoni, Giacinto Asprella Libonati and Mauro Gufoni (Asprella Libonati and Gufoni 1999; Vannucchi and Giannoni 1998) for treating unilateral lateral canal BPPV when the affected side is known.
• The maneuver proposed by Califano and colleagues (Califano et al. 2003).
• The square wave maneuver for treatment of apogeotropic lateral canal BPPV proposed by Yacovino and colleagues (Yacovino et al. 2021).
• The maneuver proposed by Lee and colleagues (Lee et al. 2022) for treating unilateral lateral canal BPPV, whether the otoliths are on the utricular side (“short arm”) or the canal-side (“long arm”) of the cupula.

Less well-studied maneuvers for treating bilateral lateral canal BPPV include:

• The Kurtzer hybrid maneuver (Gans et al. 2017).
• The hemi-precessional maneuver has been proposed for treating lateral canal BPPV when it is unilateral bilateral, or the affected side is unknown (Cherchi 2026).

Less well-studied maneuvers intended to treat BPPV involving multiple canals on the same side.  These have not yet been studied thoroughly.  If further studies prove these maneuvers to be successful, then it may become possible to treat BPPV even without knowing the affected canal(s).  Examples include:

• The Li maneuver (Li and Li 2010).
• The Barreto maneuver (Barreto et al. 2023).
• The unilateral triple canal repositioning maneuver (Cherchi 2025).

References

Asprella Libonati G, Gufoni M (1999) Vertigine Parossistica da CSL: manovre di barbecue ed altre varianti. In: Nuti D, Pagnini P, Vicini C (eds) XIV Giornate italiane di otoneurologia, XIX Giornata italiana di nistagmografia clinica, Sorrento, pp 321-336

Barreto RG, Yacovino DA, Cherchi M, Teixeira LJ, Nader SN, Leão GF (2023) Universal repositioning maneuver: a new treatment for single canal and multi-canal benign paroxysmal positional vertigo by 3-dimensional model analysis. Journal of International Advanced Otology 19: 242-247. doi: 10.5152/iao.2023.22921

Califano L, Capparuccia PG, Di Maria D, Melillo MG, Villari D (2003) Treatment of benign paroxysmal positional vertigo of posterior semicircular canal by “Quick Liberatory Rotation Manoeuvre”. Acta Otorhinolaryngol Ital 23: 161-7. 

Cherchi M (2025) Unilateral Triple Canal Repositioning Maneuver: Principles and Design. Audiology Research, vol 15. MDPI

Cherchi M (2026) Hemi-precession maneuver to treat horizontal canal benign paroxysmal positional vertigo when the affected side is unilateral, bilateral or unknown. Frontiers in Neurology Volume 16 – 2025. 

Cox H, Frith J (2025) Best practice assessment and management of benign paroxysmal positional vertigo in older adults. Age Ageing 54. doi: 10.1093/ageing/afaf225

Gans RE, Kurtzer D, McLeod H (2017) New Horizontal Canal Benign Paroxysmal Positional Vertigo Treatment: Kurtzer Hybrid Maneuver. Global Journal of Otolaryngology 6: 44-48. doi: 10.19080/GJO.2017.06.555686

Garaycochea O, Perez-Fernandez N, Manrique-Huarte R (2022) A novel maneuver for diagnosis and treatment of torsional-vertical down beating positioning nystagmus: anterior canal and apogeotropic posterior canal BPPV. Braz J Otorhinolaryngol 88: 708-716. doi: 10.1016/j.bjorl.2020.09.009

Lee DH, Park JY, Kim TH, Shin JE, Kim CH (2022) New Therapeutic Maneuver for Horizontal Semicircular Canal Cupulolithiasis: A Prospective Randomized Trial. J Clin Med 11. doi: 10.3390/jcm11144136

Li J, Li H (2010) New repositioning techniques for benign paroxysmal positional vertigo: the Li repositioning manoeuvres. J Laryngol Otol 124: 905-8. doi: 10.1017/S0022215109992520

Vannucchi P, Giannoni B Terapia della vertigine parossistica posizionale del canale semicircolare laterale, Tecniche a confronto [Treatment of lateral canal BPPV, comparison of techniques] VII Giornata di Vestibologia Pratica, ‘La terapia fisica delle vertigini periferiche’ [Practical vestibulology, ‘Physical therapy for peripheral vertigo’] 1998. CSS Formenti, Milano, pp 61-73

Yacovino DA, Zanotti E, Roman K, Hain TC (2021) Square wave manoeuvre for apogeotropic variant of horizontal canal benign paroxysmal positional vertigo in neck restricted patients. Journal of Otology 16: 65-70. doi: 10.1016/j.joto.2020.10.003