Square Wave Maneuver

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Description

The Square Wave maneuver is a treatment option for horizontal cupulolithiasis BPPV, particularly in difficult cases where the affected side is unclear, cervical mobility is restricted, or prior maneuvers have been unsuccessful. It was described as a side-independent approach that may help convert apogeotropic horizontal canal BPPV to a geotropic form or fully resolve symptoms, while minimizing the need for neck extension or cervical rotation. Current evidence is limited to a small case series, so it is best presented as a promising alternative for selected patients rather than a first-line, broadly validated maneuver (Yacovino et al., 2021; Kinne et al., 2023).

A-045 Horzontal Canal Cupulolithiasis (2)

Effectiveness 

In the initial case series, the Square Wave maneuver had a 93% success rate, with 14/15 patients responding in one session; however, no comparative trials have been published, so further validation is needed (Yacovino et al., 2021).

History

The Square Wave maneuver was published in 2021 by Yacovino, Zanotti, Roman, and Hain in Journal of Otology. Its name is descriptive, referring to the square-wave pattern created by the sequence of movements, rather than being named after a person. A key feature of the maneuver is its en bloc movement strategy, meaning the head and trunk are rotated together as one unit, which reduces the need for isolated cervical rotation during treatment

Dr. Dario Yacovino
Dr. Dario Yacovino

Instructions

The purpose is to treat apogeotropic horizontal canal BPPV by repositioning otoconia to either resolve symptoms or convert the pattern to geotropic form of BPPV.

  1. Place the patient supine with the head elevated approximately 20–30°, resting on the clinician’s hands.
  2. Rotate the patient’s head and body 90° en bloc to one side while monitoring nystagmus.
  3. When the nystagmus reaches maximum intensity, quickly rotate the patient 180° en bloc to the opposite side.
  4. After the nystagmus reverses direction and reaches peak intensity, rotate the patient back 180° again.
  5. Repeat up to 10 cycles until the apogeotropic nystagmus converts to geotropic nystagmus or resolves.
  6. Once the pattern converts, select the appropriate next maneuver based on the geotropic presentation.

Related Pathology

Horizontal cupulolithiasis 

Sources

  • Kinne, B. L., Breuer, R. E., Fitkin, O. M., & Kelly, R. L. (2023). Interventions for apogeotropic horizontal canal benign paroxysmal positional vertigo: a systematic review. Physical Therapy Reviews, 28(1), 30–38. https://doi.org/10.1080/10833196.2022.2163082 https://www.tandfonline.com/doi/full/10.1080/10833196.2022.2163082
  • Yacovino DA, Zanotti E, Roman K, Hain TC. Square wave manoeuvre for apogeotropic variant of horizontal canal benign paroxysmal positional vertigo in neck restricted patients. J Otol. 2021 Apr;16(2):65-70. doi: 10.1016/j.joto.2020.10.003. Epub 2020 Nov 5. PMID: 33777117; PMCID: PMC7985006. https://pubmed.ncbi.nlm.nih.gov/33777117/