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## Complete Summary

#### GUIDELINE TITLE

Practice parameter: therapies for benign paroxysmal positional vertigo
(an evidence-based review). Report of the Quality Standards Subcommittee
of the American Academy of Neurology.

#### BIBLIOGRAPHIC SOURCE(S)

Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC,
Herdman S, Morrow MJ, Gronseth GS, Quality Standards Subcommittee,
American Academy of Neurology. Practice parameter: therapies for benign
paroxysmal positional vertigo (an evidence-based review): report of the
Quality Standards Subcommittee of the American Academy of Neurology.
Neurology 2008 May 27;70(22):2067-74. \[38 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18505980)

#### GUIDELINE STATUS

This is the current release of the guideline.

Guidelines are updated or affirmed every three years or earlier, based
upon the availability of new evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Benign paroxysmal positional vertigo (BPPV)

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Evaluation\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Neurological Surgery\
Neurology\
Otolaryngology\
Pharmacology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To perform an evidence-based review to answer the following questions
concerning the treatment of benign paroxysmal positional vertigo (BPPV):

-   What maneuvers effectively treat posterior canal BPPV?

-   Which maneuvers are the most effective treatments for horizontal
    canal and anterior canal BPPV?

-   Are postmaneuver activity restrictions necessary after canalith
    repositioning procedure?

-   Is it necessary to include mastoid vibration with repositioning
    maneuvers?

-   What is the efficacy of Brandt--Daroff exercises, habituation
    exercises, or patient self-administered treatments for BPPV?

-   What is the efficacy of medication treatments for BPPV?

-   What are the safety and efficacy of surgical treatments for
    posterior canal BPPV?

#### TARGET POPULATION

Patients with benign paroxysmal positional vertigo (BPPV)

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Maneuvers that effectively treat posterior canal benign paroxysmal
    positional vertigo (BPPV):

    -   Canalith repositioning procedure (CRP)

    -   Semont maneuver

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2.  Self-administered Brandt-Daroff or habituation exercises
    (insufficient evidence to recommend or refute)

*The following interventions were considered but not recommended (see
the original guideline for specific context)*

1.  Self-administered Semont maneuver or CRP for posterior canal BPPV

2.  Maneuvers that treat horizontal canal BPPV:

    -   Lempert supine roll maneuver (barbecue roll)

    -   Gufoni maneuver

    -   Vanucchi--Asprella liberatory maneuver

    -   Forced prolonged positioning

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```
3.  Maneuvers that treat anterior canal BPPV

4.  Post-treatment activity restriction

5.  Addition of mastoid vibration to maneuvers

6.  Medications

7.  Surgical treatment of posterior canal BPPV

    -   Posterior semicircular canal occlusion

    -   Singular neurectomy

#### MAJOR OUTCOMES CONSIDERED

Effectiveness of treatments for resolution or improvement of symptoms of
benign paroxysmal positional vertigo (BPPV)

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

For the literature review, the following databases were searched for
relevant, fully published, peer-reviewed articles published form 1966 to
June 2006: Medline, EMBASE and Current Contents. The search terms were
as follows:\" benign paroxysmal positional vertigo,\" \"Semont
liberatory maneuver\" \"canalith repositioning maneuver,\" \"particle
repositioning maneuver,\" \"Epley maneuver,\" \"modified Epley
maneuver.\" In addition, the search was supplemented through manual
searches by panel members. At least two panelists reviewed each article
for inclusion. The literature was limited to human subjects, randomized
controlled trials, case-control or cohort studies, cases series
involving more than 6 subjects, and meta-analyses. Abstracts, reviews,
and articles with undocumented or unstated mention of improvement were
excluded.

Articles included in this analysis met all of these criteria:

1\) Benign paroxysmal positional vertigo (BPPV) was diagnosed by both
symptoms of positional vertigo lasting less than 60 seconds, and
paroxysmal positional nystagmus in response to the Dix--Hallpike
maneuver or other appropriate provocative maneuver; 2) for all forms of
BPPV, the nystagmus was characterized by a brief latency before the
onset of nystagmus or a reduction of nystagmus with repeat Dix--Hallpike
maneuvers (fatigability); 3) for posterior canal BPPV, a positive
Dix--Hallpike maneuver was defined by the presence of upbeating and
torsional nystagmus with the top pole of rotation beating toward the
affected (downside) ear; and 4) for horizontal canal BPPV, the
Dix--Hallpike or supine roll maneuver produced horizontal geotropic
(toward the ground) or apogeotropic (away from the ground)
direction-changing paroxysmal positional nystagmus. Geotropic
direction-changing positional nystagmus refers to paroxysmal right
beating nystagmus when the supine head is turned to the right and
paroxysmal left beating nystagmus with the supine head turned to the
left. Conversely, apogeotropic indicates the nystagmus is right beating
with the head turned to the left and left beating with head turned to
the right.

#### NUMBER OF SOURCE DOCUMENTS

70 articles were identified and reviewed for preparation

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Classification of Evidence for Therapeutic Intervention**

**Class I**: Prospective, randomized, controlled clinical trial with
masked or outcome assessment, in a representative population. The
following are required: (a) primary outcome(s) clearly defined; (b)
exclusion/inclusion criteria clearly defined; (c) adequate accounting
for drop-outs and cross-overs with numbers sufficiently low to have
minimal potential for bias; and (d) relevant baseline characteristics
are presented and substantially equivalent among treatment groups or
there is appropriate statistical adjustment for differences.

**Class II**: Prospective matched group cohort study in a representative
population with masked outcome assessment that meets a-d above OR a
randomized controlled trial in a representative population that lacks
one criteria a-d.

**Class III**: All other controlled trials (including well-defined
natural history controls or patients serving as own controls) in a
representative population, where outcome is independently assessed, or
independently derived by objective outcome measurement.\*

**Class IV**: Evidence from uncontrolled studies, case series, case
reports, or expert opinion.

\* Objective outcome measurement: an outcome measure that is unlikely to
be affected by an observer\'s (patient, treating physician,
investigator) expectation or bias (e.g., blood tests, administrative
outcome data).

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Otoneurologists with experience in benign paroxysmal positional vertigo
and general neurologists with methodologic expertise were invited by the
Quality Standards Subcommittee to perform the evidence review. At least
two panelists reviewed each article for inclusion. The risk of bias was
determined using the classification of evidence for each study (see
\"Rating Scheme for the Strength of the Evidence\").

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Other

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Classification of Recommendations**

The strength of practice recommendations is linked directly to the level
of evidence:

**Level A** = Established as effective, ineffective, or harmful for the
given condition in the specified population. (Level A rating requires at
least two consistent Class I studies.)

**Level B** = Probably effective, ineffective, or harmful for the given
condition in the specified population. (Level B rating requires at least
one Class I study or at least two consistent Class II studies.)

**Level C** = Possibly effective, ineffective, or harmful for the given
condition in the specified population. (Level C rating requires at least
one Class II study or two consistent Class III studies.)

**Level U** = Data inadequate or conflicting; given current knowledge,
treatment is unproven.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Draft guidelines were reviewed for accuracy, quality, and thoroughness
by the American Academy of Neurology members, topic experts, and
pertinent physician organizations.

The practice parameter was approved by the Quality Standards
Subcommittee on May 1, 2007; by the Practice Committee on June 21, 2007;
and by the American Academy of Neurology Board of Directors in July
2007.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the levels of the recommendations (A, B, C, U) and
classification of the evidence (Class I through Class IV) are provided
at the end of the \"Major Recommendations\" field.

1.  **What maneuvers effectively treat posterior canal benign paroxysmal
    positional vertigo (BPPV)?**

> *Conclusion*
>
> Two Class I studies and three Class II studies have demonstrated a
> short-term (1 day to 4 weeks) resolution of symptoms in patients
> treated with the canalith repositioning procedure (CRP), with number
> needed to treat (NNT) ranging from 1.43 to 3.7. The Semont maneuver is
> possibly more effective than no treatment (Class III), a sham
> treatment (Class II), or Brandt--Daroff exercises (Class IV) as
> treatment for posterior canal BPPV. Two Class IV studies comparing CRP
> with Semont maneuver have produced conflicting results; one showed no
> difference between groups, and the other showed a lower recurrence
> rate in patients undergoing CRP.
>
> *Recommendation*
>
> CRP is established as an effective and safe therapy that should be
> offered to patients of all ages with posterior semicircular canal BPPV
> (**Level A recommendation**). The Semont maneuver is possibly
> effective for BPPV but receives only a **Level C** recommendation
> based on a single Class II study. Although many experts believe that
> the Semont maneuver is as effective as canalith repositioning
> maneuver, based on currently published articles the Semont maneuver
> can only be classified as \"possibly effective.\" There is
> insufficient evidence to establish the relative efficacy of the Semont
> maneuver to CRP (**Level U**).

2.  **Which maneuvers are the most effective treatments for horizontal
    canal and anterior canal BPPV?**

> *Conclusion*
>
> Based on Class IV studies, variations of the Lempert supine roll
> maneuver, the Gufoni method, or forced prolonged positioning seem
> moderately effective for horizontal canal BPPV. Two uncontrolled Class
> IV studies report high response rates to maneuvers for anterior canal
> BPPV.
>
> *Recommendation*
>
> None (**Level U**)

3.  **Are postmaneuver activity restrictions necessary after canalith
    repositioning procedure?**

> *Conclusion and Recommendation*
>
> Five Class IV studies support the omission of post-treatment activity
> restrictions; one study supports the use of post-treatment
> restrictions. There is insufficient evidence to determine the efficacy
> of postmaneuver restrictions in patients treated with CRP (**Level
> U**).

4.  **Is it necessary to include mastoid vibration with repositioning
    maneuvers?**

> *Conclusion and Recommendation*
>
> One Class II, one Class III, and two Class IV studies showed no added
> benefit when mastoid vibration was added to a CRP as treatment for
> posterior canal BPPV. Mastoid oscillation is probably of no added
> benefit to patients treated with CRP for posterior canal BPPV (**Level
> C recommendation**).

5.  **What is the efficacy of Brandt--Daroff exercises, habituation
    exercises, or patient self-administered treatments for BPPV?**

> *Conclusion and Recommendation*
>
> One Class II and one Class IV study suggest that Brandt--Daroff
> exercises or habituation exercises are less effective than CRP in the
> treatment of posterior canal BPPV. Self-administered Brandt--Daroff
> exercises or habituation exercises are less effective than CRP in the
> treatment of posterior canal BPPV (**Level C**). There is insufficient
> evidence to recommend or refute self-treatment using Semont maneuver
> or CRP for BPPV (**Level U**).

6.  **What is the efficacy of medication treatments for BPPV?**

> *Conclusion and Recommendation*
>
> A single Class III study did not demonstrate that lorazepam or
> diazepam hastened resolution of symptoms in BPPV. A single Class III
> study demonstrated some benefit of flunarizine, a drug that is
> unavailable in the United States, in BPPV. There is no evidence to
> support a recommendation of any medication in the routine treatment
> for BPPV (**Level U**).

7.  **What are the safety and efficacy of surgical treatments for
    posterior canal BPPV?**

> *Conclusion and Recommendation*
>
> Six unblinded, retrospective Class IV studies report relief from
> symptoms of BPPV in nearly every patient undergoing posterior
> semicircular canal occlusion or singular neurectomy. Because the
> studies are Class IV, they do not provide sufficient evidence to
> recommend or refute posterior semicircular canal occlusion or singular
> neurectomy as treatment for BPPV (**Level U**).

**[Definitions]{.underline}**:

**Classification of Evidence for Therapeutic Intervention**

**Class I**: Prospective, randomized, controlled clinical trial with
masked or outcome assessment, in a representative population. The
following are required: (a) primary outcome(s) clearly defined; (b)
exclusion/inclusion criteria clearly defined; (c) adequate accounting
for drop-outs and cross-overs with numbers sufficiently low to have
minimal potential for bias; and (d) relevant baseline characteristics
are presented and substantially equivalent among treatment groups or
there is appropriate statistical adjustment for differences.

**Class II**: Prospective matched group cohort study in a representative
population with masked outcome assessment that meets a-d above OR a
randomized controlled trial in a representative population that lacks
one criteria a-d.

**Class III**: All other controlled trials (including well-defined
natural history controls or patients serving as own controls) in a
representative population, where outcome is independently assessed, or
independently derived by objective outcome measurement.\*

**Class IV**: Evidence from uncontrolled studies, case series, case
reports, or expert opinion.

\* Objective outcome measurement: an outcome measure that is unlikely to
be affected by an observer\'s (patient, treating physician,
investigator) expectation or bias (e.g., blood tests, administrative
outcome data).

**Classification of Recommendations**

**Level A** = Established as effective, ineffective, or harmful for the
given condition in the specified population. (Level A rating requires at
least two consistent Class I studies.)

**Level B** = Probably effective, ineffective, or harmful for the given
condition in the specified population. (Level B rating requires at least
one Class I study or at least two consistent Class II studies.)

**Level C** = Possibly effective, ineffective, or harmful for the given
condition in the specified population. (Level C rating requires at least
one Class II study or two consistent Class III studies.)

**Level U** = Data inadequate or conflicting; given current knowledge,
treatment is unproven.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate use and best practices for treatment of patients with benign
paroxysmal positional vertigo (BPPV)

#### POTENTIAL HARMS

In some studies of patients with posterior canal benign paroxysmal
positional vertigo (BPPV) treated with a canalith repositioning
procedure, complications of nausea and vomiting, fainting, or conversion
to horizontal or anterior canal BPPV occurred.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This statement is provided as an educational service of the American
Academy of Neurology. It is based on an assessment of current scientific
and clinical information. It is not intended to include all possible
proper methods of care for a particular neurologic problem or all
legitimate criteria for choosing to use a specific procedure. Neither is
it intended to exclude any reasonable alternative methodologies. The
American Academy of Neurology recognizes that specific patient care
decisions are the prerogative of the patient and the physician caring
for the patient, based on all of the circumstances involved.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources\
Quick Reference Guides/Physician Guides\
Resources\
Slide Presentation\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC,
Herdman S, Morrow MJ, Gronseth GS, Quality Standards Subcommittee,
American Academy of Neurology. Practice parameter: therapies for benign
paroxysmal positional vertigo (an evidence-based review): report of the
Quality Standards Subcommittee of the American Academy of Neurology.
Neurology 2008 May 27;70(22):2067-74. \[38 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18505980)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2008 May 27

#### GUIDELINE DEVELOPER(S)

American Academy of Neurology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Neurology (AAN)

#### GUIDELINE COMMITTEE

Quality Standards Subcommittee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: T.D. Fife, MD; D.J. Iverson, MD; T. Lempert, MD; J.M.
Furman, MD, PhD; R.W. Baloh, MD; R.J. Tusa, MD, PhD; T.C. Hain, MD; S.
Herdman, PT, PhD, FAPTA; M.J. Morrow, MD; G.S. Gronseth, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The American Academy of Neurology (AAN) is committed to producing
independent, critical and truthful clinical practice guidelines (CPGs).
Significant efforts are made to minimize the potential for conflicts of
interest to influence the recommendations of this CPG. To the extent
possible, the AAN keeps separate those who have a financial stake in the
success or failure of the products appraised in the CPGs and the
developers of the guidelines. Conflict of interest forms were obtained
from all authors and reviewed by an oversight committee prior to project
initiation. AAN limits the participation of authors with substantial
conflicts of interest. The AAN forbids commercial participation in, or
funding of, guideline projects. Drafts of the guidelines have been
reviewed by at least three AAN committees, a network of neurologists,
*Neurology* peer reviewers, and representatives from related fields. The
AAN Guideline Author Conflict of Interest Policy can be viewed at
[www.aan.com](http://www.aan.com/).

The authors report the following disclosures: Dr. Fife has received
research support from GlaxoSmithKline and estimates that 6% of his time
is spent on canalith repositioning procedures. Dr. Iverson has nothing
to disclose. Dr. Lempert estimates that \<5% of his time is spent on
videooculography. Dr. Furman holds stock options in Neurokinetics, has
received research support from Merck, has served as an expert witness on
vestibular function, and estimates that 1% of his time is spent on the
Epley maneuver. Dr. Baloh estimates 5% of his time is spent on ENG. Dr.
Tusa estimates that 5% of his time is spent on quantified positional
testing. Dr. Hain estimates that 5% of his time is spent on ENG and 5%
on VEMP. Dr. Herdman received research support from VAMC and served as
an expert witness on the Hallpike--Dix maneuver. Dr. Morrow has received
honoraria from BiogenIdec and has served as an expert witness and
consultant on medico-legal proceedings. Dr. Gronseth has received
speaker honoraria from Pfizer, GlaxoSmithKline, and Boehringer Ingelheim
and served on the IDMC Committee of Ortho-McNeil.

#### GUIDELINE STATUS

This is the current release of the guideline.

Guidelines are updated or affirmed every three years or earlier, based
upon the availability of new evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: A list of American Academy of Neurology (AAN)
guidelines, along with a link to a Portable Document Format (PDF) file
for this guideline, is available at the [AAN Web
site](http://www.aan.com/go/practice/guidelines).

Print copies: Available from the AAN Member Services Center, (800)
879-1960, or from AAN, 1080 Montreal Avenue, St. Paul, MN 55116.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Therapies for benign paroxysmal positional vertigo. AAN summary of
    evidence-based guidelines for clinicians. St. Paul (MN): American
    Academy of Neurology. 2008. 2 p. Available in Portable Document
    Format (PDF) from the [American Academy of Neurology Web
    site](http://www.aan.com/practice/guideline/uploads/290.pdf).

-   Practice parameter: therapies for benign paroxysmal positional
    vertigo (an evidence-based review). Report of the Quality Standards
    Subcommittee of the American Academy of Neurology. Slide
    presentation. St. Paul (MN): American Academy of Neurology. 2008.
    71 p. Available from the [AAN Web
    site](http://www.aan.com/practice/guideline/uploads/292.ppt).

-   Practice parameter: therapies for benign paroxysmal positional
    vertigo (an evidence-based review). Report of the Quality Standards
    Subcommittee of the American Academy of Neurology. Case study and
    coding. St. Paul (MN): American Academy of Neurology. 2008. 3 p.
    Available from the [AAN Web
    site](http://www.aan.com/practice/guideline/uploads/296.pdf).

-   Practice parameter: therapies for benign paroxysmal positional
    vertigo (an evidence-based review). Report of the Quality Standards
    Subcommittee of the American Academy of Neurology. Podcast. St. Paul
    (MN): American Academy of Neurology. 2008. Available from the [AAN
    Web site](http://www.aan.com/go/practice/guidelines/podcast).

-   Practice parameter: therapies for benign paroxysmal positional
    vertigo (an evidence-based review). Report of the Quality Standards
    Subcommittee of the American Academy of Neurology. BPPV maneuvers
    video. St. Paul (MN): American Academy of Neurology. 2008. Available
    from the [AAN Web
    site](http://www.aan.com/practice/guideline/index.cfm?fuseaction=home.view&guideline=293).

-   AAN guideline development process \[online\]. St. Paul (MN):
    American Academy of Neurology. Available from the [AAN Web
    site](http://www.aan.com/go/practice/guidelines/development).

#### PATIENT RESOURCES

The following is available:

-   Treating benign paroxysmal positional vertigo. AAN summary of
    evidence-based guideline for patients and their families. St. Paul
    (MN): American Academy of Neurology (AAN). 2008. 2 p.

Electronic copies: Available in Portable Document Format (PDF) from the
[AAN Web site](http://www.aan.com/practice/guideline/uploads/291.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI Institute on October 31, 2008. The
information was verified by the guideline developer on December 11,
2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Academy of Neurology.

### DISCLAIMER

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Date Modified: 1/5/2009