Experiences of patients and their health care providers with canalith repositioning maneuvers for benign paroxysmal positional vertigo: a qualitative systematic review protocol : JBI Evidence Synthesis

Secondary Logo

Journal Logo


Experiences of patients and their health care providers with canalith repositioning maneuvers for benign paroxysmal positional vertigo: a qualitative systematic review protocol

Vasanthan, Lenny Thinagaran1; Sriram, Vimal2; Chockalingam, Manigandan3

Author Information
doi: 10.11124/JBIES-21-00478
  • Free



Benign paroxysmal positional vertigo (BPPV) is defined as an inner ear disorder characterized by repeated, short-duration episodes of positional vertigo. Vertigo refers to the sensation of movement in the absence of actual movement, which occurs suddenly and lasts for less than a minute (paroxysmal). Positional vertigo refers to symptoms of vertigo elicited by changes in head position relative to gravity.1,2 BPPV is among the most common causes of idiopathic vertigo in primary and secondary health care settings.2,3 Many interventions, such as vestibular suppressant medications, repositioning maneuvers, and habituation exercises, are used to manage BPPV.2

The canalith repositioning maneuver (CRM) is a popular and strongly recommended first-line intervention for individuals with BPPV.2 CRM is a “group of procedures in which the patient moves through specific body positions designed to relocate dislodged particles within the inner ear for the purpose of relieving symptoms of BPPV.”2(p.406) Many variations in CRM specific to canal involvement have been reported. Irrespective of the variations, these maneuvers require only a series of head and trunk positions. The positions are simple and readily implemented at the health care provider's office, requiring no more than an examination table,4 chair,5 or stretcher capable of tilting.6

Despite being simple and effective, a nationwide survey of health care providers in Lithuania found that only 16% of general practitioners and 39% of ear, nose, and throat physicians provided CRM for their patients with BPPV, contrary to recommendations in the guidelines.7 Health care providers underutilize CRM because of fear of provoking symptoms and side effects, limited availability of time, and lack of confidence in performing the technique.7 Emergency department physicians from the United States reported similar experiences of forgetting how to perform CRM or not having enough knowledge to provide CRM, resulting in underutilization.8 In addition, these physicians indicated that past positive or negative experiences with CRM played a role in facilitating or inhibiting CRM implementation in their BPPV care delivery. Therefore, understanding and documenting the experiences of health care providers with CRM is crucial to identifying commonly perceived facilitators and barriers to CRM.

Apart from the experiences of health care providers offering CRM, patient experiences of undergoing CRM are also important. Patients who have been treated with CRM have reported a variety of experiences. Some rare and self-limiting complications have been reported during and after CRM, including canal conversion (debris accidentally moved from one canal to another), nausea, vomiting, and fainting.9,10 Other complications of this maneuver include postural instability for up to 24 hours11 and a heightened sense of falling for up to 30 minutes afterwards.12 Patients report physical discomfort and anxiety immediately after CRM, regardless of their age, but these symptoms tend to subside steadily after the procedure.13 In fact, patients with BPPV commonly experience anxiety or depression, with studies reporting that approximately 1 in 2 patients have these common psychological symptoms.14 Such symptoms can adversely affect the outcome of CRM, as this cohort is more likely to experience residual dizziness despite effective treatment, making their experiences even more important and unique.14 Therefore, better ways to ensure patient comfort during and after CRM treatment are needed to enhance positive experiences, greater acceptance of CRM, and eventual improvement in CRM effectiveness. Comprehensively documenting all types of patient experiences with CRM, including complications, is the first step toward developing a CRM protocol that ensures patient comfort.

Documenting complications following any medical intervention is crucial, but patient experience as a whole also determines health and is an indicator of the quality of health care.15 Many factors, such as access to health care, communication with a health care professional, the experience of the actual intervention received, the simplicity/complexity of the intervention technique, and so on, affect the patient experience.16 Having a clear understanding of intervention-specific patient experiences is of critical importance in increasing the acceptance of any intervention and its delivery protocol,17 and clinically effective CRM is no exception. Research and systematic reviews that evaluate CRM's efficacy are important, but it is equally important to understand how patients and health care providers perceive CRM. This is necessary for both an improved understanding of the impact CRM has on patients with BPPV and for an understanding of how the patients’ broader sociocultural health care system impacts their ability to receive optimal CRM treatment. This understanding will provide a basis for defining the essential aspects of patient-centered care of CRM and patient–professional interactions. It will also help identify barriers or facilitators of effective, evidence-based CRM in all resource settings, which will eventually enhance CRM delivery protocols and service provision. Moreover, the results can be used to train health care providers in effective and patient-centered CRM.

A preliminary search of PROSPERO, MEDLINE, Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted on December 10, 2021. The search did not identify any current or in-progress scoping or systematic reviews that focus on patients’ experiences of CRM, including complications and adverse events, or health care providers’ experiences with CRM. Therefore, to effectively implement this valuable and effective intervention, a systematic qualitative review addressing the full spectrum of experiences of individuals subjected to CRM and the experiences of health care providers offering CRM is necessary.

The objective of this review is to identify and synthesize the available evidence on the experiences of patients undergoing CRM (provided by health care providers or by the patients themselves) and the experience of health care providers offering CRM in BPPV.

Review questions

  • i) What are patients’ experiences with self-provision of CRM for treating BPPV?
  • ii) What are patients’ experiences of receiving CRM from health care providers for treating BPPV?
  • iii) What are health care providers’ experiences, perspectives, and opinions, including facilitators and barriers, of providing CRM?

Inclusion criteria


This review will consider studies that include patients with BPPV of all age groups who were treated with CRM by their health care provider or by themselves as part of the self-administration of CRM, with or without other interventions for BPPV. A patient's BPPV can be their first episode or a recurrent episode (the recurring of positional vertigo after successful treatment with a minimum duration of 1 week of remission).18 Patients with BPPV, including those with chronic diseases such as diabetes or hypertension, will be included in this review. Studies reporting non-paroxysmal and/or non-positional vertigo, either caused by peripheral vestibular disorders (such as labyrinthitis or vestibular neuritis) or central vestibular disorders (such as vestibular migraine, cerebrovascular accidents, or vertebrobasilar insufficiency), will be excluded. Patients with blindness, pregnant women, or women in the postpartum period up to 6 months, will be excluded. Where participants’ diagnosis of BPPV is unclear/unavailable or where participants self-referred to the health care provider and received CRM as treatment, we will assume that BPPV is not caused by the conditions listed in the exclusion criteria in those studies.

The review will also include health care providers who offer CRM, such as physiotherapists, occupational therapists, general practitioners, otolaryngologists, neurologists, speech and language pathologists, and nurses, regardless of their experience level as CRM providers. Citations stating that CRM was provided by non-qualified health professionals, such as student health professionals, health care assistants, or technicians who are not able to practice their profession without the supervision of qualified health professionals, will be excluded. Similarly, CRM provided by non-professional caregivers, family caregivers, volunteer caregivers, or other informal caregivers will also be excluded.

Phenomena of interest

In this review, studies that describe the experiences of patients with CRM and/or their health care providers will be considered. The patients’ experiences during or after CRM treating their first or recurrent episode of BPPV can be classified as positive, negative, complications/adverse events, or any other experiences. The health care providers’ experiences may include facilitators and barriers, encounters, perspectives, or opinions associated with preparing for CRM delivery or providing CRM to treat first or recurrent episodes of BPPV.


There will be no restrictions on the context of reviews, and CRM interventions in any clinical setting (eg, outpatient, inpatient, community-based, home-based intervention services, or other therapeutic settings) will be considered for inclusion in the review. This review is not restricted to geographical locations, health care facilities, or services.

Types of studies

This review will consider studies that focus on qualitative data, including, but not limited to, designs such as qualitative descriptive, phenomenology, grounded theory, ethnography, action research, and feminist research. This review will also consider the qualitative results of mixed method studies.


The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.19 The review title is registered in PROSPERO (CRD42021292993).

Search strategy

The search strategy will aim to locate both published and unpublished studies. A 3-step search strategy will be utilized in this review. First, an initial limited search of MEDLINE (Ovid) and CINAHL (EBSCO) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE via Ovid (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included database and/or information source. The reference lists of all included sources of evidence will be screened for additional studies.

Interpreting qualitative systematic reviews requires fluency in a specific language, and since the review team has limited language proficiency in languages other than English and there are limited resources available for translations, languages other than English will not be included.20 There will be no restrictions on publication date. Database searches will include MEDLINE (Ovid), Embase, Cochrane CENTRAL, PsycINFO, Scopus, Web of Science, and CINAHL (EBSCO). Gray literature, namely, OpenGrey, PsyArXiv, bioRxiv, medRxiv, and Google Scholar, will also be searched.

Study selection

After the search, citations will be collated and uploaded into EndNote v.X20 (Clarivate Analytics, PA, USA), and duplicates removed. In accordance with Cochrane's recommendation, a pilot test of the eligibility criteria will be carried out on a sample of citations (between 6 and 8 articles, which will include articles determined to be definitely eligible, definitely ineligible, and doubtful) in order to ensure the application of the criteria is consistent.21 Two independent reviewers will then screen the titles and abstracts to determine whether they meet the review's inclusion criteria. Potentially relevant studies will be retrieved in full, and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).22 The full text of selected citations will be assessed in detail against the inclusion criteria by 2 independent reviewers. The reasons for the exclusion of full-text papers that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion or with an additional reviewer. The results of the search and the study inclusion process will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.23

Assessment of methodological quality

Eligible studies will be critically appraised by 2 independent reviewers for methodological quality using the standard JBI critical appraisal checklist for qualitative research.24 Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of the critical appraisal will be reported in narrative format and tables.

Regardless of the results of their methodological quality, all studies will be included in the data extraction and synthesis process to ensure that all experiences are captured comprehensively, and no evidence is missed. However, quality issues will be presented and discussed in the review.

Data extraction

Data will be extracted from studies included in the review by 2 independent reviewers using the standardized JBI data extraction tool in JBI SUMARI.22 The data extracted will include specific details about the population, context, culture, geographical location, study methods, and the phenomena of interest relevant to the review objectives, namely, experiences of CRM by a person with BPPV and health care providers’ experiences of CRM provision, including facilitators and barriers to CRM provision. The findings, and their illustrations, will be extracted verbatim and assigned a level of credibility. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. If necessary, missing or additional data will be requested from the authors.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.24 This will involve the aggregation or synthesis of findings to generate a set of statements representing that aggregation by assembling the findings and categorizing these findings based on similarity in meaning. These categories will then be subjected to a synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative format. Only unequivocal and credible findings will be included in the synthesis.

Assessing confidence in the findings

The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.25 The Summary of Findings will include the major elements of the review and detail how the ConQual score was developed. The title, population, phenomena of interest, and context for the specific review will be included in the Summary of Findings. Each synthesized finding from the review will then be presented, along with the type of research informing it, the score for dependability and credibility, and the overall ConQual score.


Ms. Rachel Rajasekaran, Ms. Dolly Mira Priyadarshini, and Dr. Caroline Hills for reviewing our manuscript.

Author contributions

LTV and MC conceived the design of the study. LTV, MC, and VS developed the search strategy and conducted the search. MC drafted the protocol with critical revision and input from LTV and VS. All authors have read and approved this version. MC is the guarantor of the review.

Appendix I: Search strategy


Searched: March 11, 2021

1 exp Vertigo/ or exp Benign Paroxysmal Positional Vertigo/ or exp Dizziness/nu, pc, px, rh, th or exp Nystagmus, Pathologic/ or exp Nystagmus, Optokinetic/ or exp Nystagmus, Physiologic/ or exp Vestibular Diseases/ or Canalithiasis.mp. or Cupulolithiasis.mp. or bppv.mp. or paroxysmal.mp. or dizz.mp. (Records Retrieved – 76,604)

2 exp Head Movements/ or exp Physical Therapy Modalities/ or exp Patient Positioning/ae, is, mt, mo, nu, px or head movement.mp. or physical therapy.mp. or physiotherapy.mp. or physio therapy.mp. or epley.mp. or semont.mp. or canalith.mp. or otolith.mp. or particle.mp. or position.mp. or reposition.mp. or re-position.mp. or maneuver.mp. or manoeuvr.mp. or liberatory technique.mp. or Dix Hallpike.mp. or Vestibular rehabilitation.mp. (Records Retrieved – 1,151,796)

3 exp ”Quality of Health Care“/ or exp Patient Satisfaction/ or exp Patient Compliance/ or exp Compliance/ or exp ”Patient Acceptance of Health Care“/ or exp ”Treatment Adherence and Compliance“/ or exp Patient Dropouts/ or exp Treatment Refusal/ or exp Patient Participation/ or exp Psychological Distress/ or exp Health Behavior/ or exp ”Quality of Life“/ or exp Attitude/ or exp Qualitative Research/ or patient satisfaction.mp. or patient acceptance.mp. or patient dropout.mp. or patient participation.mp. or treatment refus.mp. or experience.mp. or feel.mp. or encounter.mp. or perception.mp. or opinion.mp. (Records Retrieved – 9,060,216)

4 exp Health Personnel/ or exp Allied Health Personnel/ or exp Physicians/ or exp General Practitioners/ or exp Family Practice/ or exp Geriatricians/ or exp Otolaryngologists/ or exp Neurologists/ or exp Physicians, Family/ or exp Physician Assistants/ or exp Primary Health Care/ or exp Emergency Medical Services/ or exp Emergency Medical Technicians/ or exp Nurses/ or exp Family Nurse Practitioners/ or exp Nurse Practitioners/ or exp Audiologists/ or exp Physical Therapists/ or exp Occupational Therapists/ or health personnel.mp. or healthcare professional.mp. or health-care professional.mp. or health care professional.mp. or allied health professional.mp. or doctor.mp. or general practitioner.mp. or physician.mp. or geriatric.mp. or neurologist.mp. or neuro.mp. or otolaryngologist.mp. or (ear nose and throat).mp. or ENT.mp. or vestibular special.mp. or prescriber.mp. or primary healthcare.mp. or paramedic.mp. or family nurse.mp. or nurse.mp. or community nurse.mp. or physio.mp. or physiotherapist.mp. or physio therapist.mp. or physical therapist.mp. or SLT.mp. or (speech and language therapist).mp. or speech therapist.mp. or ENT.mp. or vestibular special.mp. or self treatment.mp. or (health care professional or health care professionals or health care provider or health care providers or healthcare provider or healthcare providers or healthcare worker or healthcare workers or personnel, health or professional, health care or provider, health care or provider, healthcare).mp. (Records Retrieved – 8,690,878)

5 exp ”Attitude of Health Personnel“/ or exp Attitude/ or exp Occupational Stress/ or exp ”Delivery of Health Care"/ or exp Qualitative Research/ or experience.mp. or feel.mp. or encounter.mp. or perception.mp. or opinion.mp. (Records Retrieved – 2,992,184)

6 4 and 5 (Records Retrieved – 1,226,201)

7 3 or 6 (Records Retrieved – 9,188,245)

8 1 and 2 and 7 (Records Retrieved – 4124)


1. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2014; (12):CD003162.
2. Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg 2017;156: (3_suppl): S1–S47.
3. Hunt WT, Zimmermann EF, Hilton MP. Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database Syst Rev 2012; (4):CD008675.
4. Nguyen CT, Basso M. Epley maneuver [internet]. Treasure Island (FL): StatPearls Publishing; 2021.
5. Michael P, Muñoz D, Tuma A, Gárate M, Barraza C, Nuñez M, et al. A Chair-based Abbreviated Repositioning Maneuver (ChARM) for fast treatment of posterior BPPV. Eur Arch Otorhinolaryngol 2019;276 (8):2191–2198.
6. Edwards C, Franklin E. Vestibular rehabilitation [internet]. Treasure Island (FL): StatPearls Publishing; 2021.
7. Ulytė A, Valančius D, Masiliūnas R, Paškonienė A, Lesinskas E, Kaski D, et al. Diagnosis and treatment choices of suspected benign paroxysmal positional vertigo: current approach of general practitioners, neurologists, and ENT physicians. Eur Arch Otorhinolaryngol 2019;276 (4):985–991.
8. Kerber KA, Forman J, Damschroder L, Telian SA, Fagerlin A, Johnson P, et al. Barriers and facilitators to ED physician use of the test and treatment for BPPV. Neurol Clin Pract 2017;7 (3):214–224.
9. Herdman SJ, Tusa RJ. Complications of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg 1996;122 (3):281–286.
10. Yimtae K, Srirompotong S, Srirompotong S, Sae-Seaw P. A randomized trial of the canalith repositioning procedure. Laryngoscope 2003;113 (5):828–832.
11. Sridhar S, Panda N. Particle repositioning manoeuvre in benign paroxysmal positional vertigo: is it really safe? J Otolaryngol 2005;34 (1):41–45.
12. Uneri A. Falling sensation in patients who undergo the Epley maneuver: a retrospective study. Ear Nose Throat J 2005;84 (2):82,84-5.
13. Maas BDPJ, Bruintjes TD, van der Zaag-Loonen HJ, Winters SM, Masius-Olthof S, Colijn C, et al. Physical and emotional burden of the Epley maneuver in the elderly. Otol Neurotol 2019;40 (8):1082–1087.
14. Wei W, Sayyid ZN, Ma X, Wang T, Dong Y. Presence of anxiety and depression symptoms affects the first time treatment efficacy and recurrence of benign paroxysmal positional vertigo. Front Neurol 2018;9:178.
15. Oben P. Understanding the patient experience: a conceptual framework. J Patient Exp 2020;7 (6):906–910.
16. Clarke GM, Conti S, Wolters AT, Steventon A. Evaluating the impact of healthcare interventions using routine data. BMJ 2019;365:l2239.
17. Nakarada-Kordic I, Patterson N, Wrapson J, Reay SD. A systematic review of patient and caregiver experiences with a tracheostomy. Patient 2018;11 (2):175–191.
18. Zhu CT, Zhao XQ, Ju Y, Wang Y, Chen MM, Cui Y. Clinical characteristics and risk factors for the recurrence of benign paroxysmal positional vertigo. Front Neurol 2019;10:1190.
19. Lockwood C, Porritt K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M. Aromataris E, Munn Z, et al. Chapter 2: Systematic reviews of qualitative evidence. JBI, JBI Manual for Evidence Synthesis [internet]. Adelaide:2020.
20. Soilemezi D, Linceviciute S. Synthesizing qualitative research: reflections and lessons learnt by two new reviewers. Int J Qual Methods 2018;17 (1):1–14.
21. Lefebvre C, Glanville J, Briscoe S, Featherstone R, Littlewood A, Marshall C, et al. Chapter 4: Searching for and selecting studies. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al., editors. Cochrane handbook for systematic reviews of interventions version 6.3 [internet]. Cochrane; 2022 [cited 2022 Mar 2]. Available from: https://training.cochrane.org/handbook.
22. Munn Z, Aromataris E, Tufanaru C, Stern C, Porritt K, Farrow J, et al. The development of software to support multiple systematic review types: the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Int J Evid Based Healthc 2019;17 (1):36–43.
23. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. J Clin Epidemiol 2021;134:178–189.
24. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc 2015;13 (3):179–187.
25. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC Med Res Methodol 2014;14:108.

BPPV; dizziness; health care providers; health personnel; qualitative research

© 2022 JBI