Principles

Comparative evidence

Across all three canals, repositioning manoeuvres resolve 70–95% of BPPV, often after a single session. The evidence is strongest for the posterior and horizontal canals and thinner — but expanding — for the anterior canal.

For posterior-canal BPPV, the Epley and Semont manoeuvres show similar benefit, with most RCTs reporting 80–95% resolution after one to three sessions and strong evidence over sham.1,2 For the horizontal canal, the Gufoni and Lempert manoeuvres are comparably effective, both significantly outperforming sham; the Gufoni is preferred for its brevity in frail or older patients.3 For the anterior canal, the Yacovino is the best-studied first-line technique, with case-series cure rates of 70–100% but limited controlled data.4

Reported resolution rates by manoeuvre (range across cited studies). Posterior- and horizontal-canal manoeuvres rest on RCT-level evidence; anterior-canal figures come from smaller series.

Posterior canal

Epley

80–95%

Semont

85–90%

Brandt–Daroff

50–70%

Horizontal canal

Lempert roll

75–92%

Gufoni

80–90%

Forced prolonged positioning

60–85%

Anterior canal

Yacovino

70–100%

Deep head-hanging

85–95%

Comparative efficacy of canalith repositioning manoeuvres in BPPV
Canal	Manoeuvre	Efficacy	Strengths	Evidence level
Posterior	Epley	80–95% in 1–3 sessions	Well-established, reproducible	High — RCTs, Cochrane review
Posterior	Semont	≈85–90% (comparable to Epley)	Faster; good with cervical limitation	Moderate–high — RCTs, clinical trials
Posterior	Brandt–Daroff	50–70% short-term; good long-term	Home-based; useful in recurrence	Moderate — clinical series, guidelines
Horizontal	Lempert (barbecue)	75–92% after 1–2 cycles	Highly effective for geotropic HC-BPPV	High — RCTs, meta-analyses
Horizontal	Gufoni	≈80–90%	Simple, quick; geotropic & apogeotropic	High — RCTs, systematic reviews
Horizontal	Casani / Zuma	Promising (esp. apogeotropic)	Easier for elderly; resistant cases	Low–moderate — case series, pilot studies
Horizontal	Forced prolonged positioning	≈60–85% (adherence-dependent)	Non-invasive; home / residual symptoms	Moderate — prospective cohorts
Anterior	Yacovino	70–100% in small series	Non-lateralising; simple; safe for elderly	Moderate — clinical series, observational
Anterior	Deep head-hanging	≈85–95% in case series	Effective alternative to Yacovino	Moderate — case series, biomechanical
Anterior	Reverse (short) Epley	Variable; lower than Yacovino	Follows known repositioning logic	Low — simulations, small series

Two caveats temper the table. Apogeotropic horizontal-canal variants treated by the Casani/Zuma manoeuvre rest on small series and await larger validation.5 And forced prolonged positioning, though useful as an adjunct, is adherence-dependent and slower in onset.6 Anterior-canal evidence in general remains the weakest, with a recognised need for large-scale RCTs.