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admin | Bv Homeopathic Treatment | 13.04.2016
Benign paroxysmal positional vertigo (BPPV): A balance disorder that results in the sudden onset of dizziness, spinning, or vertigo when moving the head. It's not easy staying still, but the spinning wheel going round-and-round forced me down and I lay prone for weeks, whispering to myself and watching the clouds drift by. Benign Paroxysmal Positional Vertigo:Continuing Professional Development Package - Physiopedia, universal access to physiotherapy knowledge.
The aim of this continuing professional development (CPD) package is to educate physiotherapists and increase awareness about Benign Paroxysmal Positional Vertigo (BPPV) in an aging population.
Not all aspects of BPPV are covered in-depth, but you are encouraged to use this package and its links as a guide to further your understanding of the condition and to guide future learning. BPPV is a peripheral vestibular disorder characterized by short episodes of mild to intense dizziness and influenced by specific changes in head position. BPPV occurs when the otoconia of the macula are dislodged and transferred into the lumen of one of the semicircular canals.
Following this phenomenon, nystagmus ensues as a result of either canalithiasis or cupulolithiasis. The exact reason for the calcium crystals separating from the macula is not well understood. BPPV is an idiopathic condition with approximately 50-70% of cases occurring without any known cause. The high percentage of undiagnosed patients is testament to the lack of knowledge surrounding BPPV.
The signs and symptoms of BPPV are often transient, with symptoms commonly lasting less than one minute (paroxysmal).[8] Episodes of BPPV can resolve after a few weeks or months, but may reappear at a later time. Activities that bring about the signs and symptoms of BPPV can vary from person to person, but are almost always brought on by a change in the position of the head. BPPV can easily be diagnosed and treated through simple clinic-based procedures.[9] In the past, a wide variety of different tests and procedures have been explored for diagnosis of BPPV, but many of these techniques have been discredited in recent years.
Different studies have aimed to identify and validate useful questions when suspecting a diagnosis of BPPV. Once the subjective assessment is complete, the health care professional should have a good idea whether further investigation is needed. If details of the subjective assessment and patient history indicate BPPV, then further physical investigation is needed to confirm a diagnosis. Evidence-based guidelines state that clinicians should diagnose posterior canal BPPV when vertigo and associated nystagmus is provoked by the Dix-Hallpike maneuver. Prior to initiation of the maneuver clinicians should explain the basic features of the test and warn patients that it may provoke sudden onset of vertigo. Step 2) The examiner rotates the patient’s head 45° to one side and positions their own body so that rotation may be maintained through the next portion of the maneuver. Step 3) With the head fully supported and maintained at 45° of rotation, the examiner quickly moves the patient from the seated position to a supine position with the patient’s neck extended 20° off the edge of the examination table. Step 4) After resolution of vertigo and nystagmus, the patient is slowly returned to the upright position. Step 5) The entire maneuver should then be repeated with the head rotated to the opposite side. A positive Dix-Hallpike maneuver will elicit a typical pattern of nystagmus described as a mix of torsional and vertical movement, with the upper pole of the eye beating toward the downward facing affected ear.[9] If one ear is affected, nystagmus will be provoked when the affected ear is positioned downwards and not upwards. Step 1) The patient is initially positioned in supine with the head in a neutral position over the edge of the table. Step 2) With support from the clinician, the head is quickly rotated 90° to one side with the clinician observing the eyes for nystagmus. Step 3) After any elicited nystagmus has resided, the head is returned to neutral and the eyes are once again observed for nystagmus. A positive supine roll test will evoke two different patterns of nystagmus, which reflect the two different types of lateral canal BPPV. In 1992, Epley[19] first described the Canalith Repositioning Procedure (CRP) and demonstrated that 100% of the patients’ symptoms were relieved with this technique. Step 1) Place the patient in a sitting position with the head turned away from the affected side Figure 6. While less common, lateral BPPV can be caused by particles within the lateral semicircular canal. The prolonged position maneuver can be used for lateral BPPV and involves the patient lying on their side with the affected ear up for 12 hours.
The evidence for both of these treatment techniques is of low quality and further research is needed. The Brandt-Daroff exercises may be summarized in the following steps (see Figure 7): Figure 7.
Falling is not just a problem attributed to the UK; approximately 40% of the population over the age of 65 in the USA falls at least once a year, with 1 in 40 of them being admitted to hospital.
These facts and figures clearly highlight the huge economic impact of falls on the NHS and financial obligation which accompanies treatment of associated injuries.
Due to the increased prevalence of BPPV with age, patients suffering from this condition will often have medical comorbidities which need to be taken into consideration when diagnosing and treating BPPV.
Acquiring a good knowledge of the pathophysiology, diagnosis and treatment techniques involved in the management of BPPV allows for early diagnosis and effective intervention. Due to the high recurrence rate of BPPV, it is recommended that patients are educated as to how to self-manage the condition so that if it does present itself again, the patient is able to treat themselves accordingly. An increased knowledge and awareness of BPPV will have a positive impact on the health of the elderly population and their quality of life.

The following set of self-test questions has been developed to test your knowledge on BPPV and to encourage self-reflection on current practice. 8) Think about how you might describe the Dix-Hallpike maneuver and Supine Roll Test to the patient. 9) Using the links provided watch videos on the diagnostic and treatment techniques discussed in this package. The most common causes are benign paroxysmal positional vertigo and vestibular migraine while less common causes include Meniere’s disease and vestibular neuritis. Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway. Vertigo caused by problems with the inner ear or vestibular system is called peripheral vertigo.
If vertigo arises from the balance centers of the brain, it is usually milder, and has accompanying neurologic deficits, such as slurred speech, double vision or pathologic nystagmus.
A number of conditions that involve the central nervous system may lead to vertigo including: migraine headaches, lateral medullary syndrome, multiple sclerosis. Benign paroxysmal positional vertigo (BPPV) is brief periods of vertigo (less than one minute) which occur with change in position. Meniere’s disease frequently presents with vertigo in combination with ringing in the ears, a feeling of pressure or fullness, severe nausea or vomiting, and hearing loss. Motion sickness is one of the biggest symptoms of vertigo and it develops most often in persons with inner ear problems.
The Dix-Hallpike test is performed with the patient sitting upright with the legs extended.
Daily exercise designed to ensure clearance of the debris (otoconia) and facilitate full resolution of vertigo symptoms. The Epley maneuver is also called the particle repositioning or canalith repositioning procedure.
Thanks to a friend's referral, I was blessed to be treated by a brilliant, vestibular physiotherapist with boffo bedside manner, who diagnosed me with benign paroxysmal positional vertigo (BPPV) and then kicked its butt out of my inner ear.
It introduces some of the current issues surrounding management of BPPV and aims to help reduce falls and unplanned hospital admissions by encouraging early diagnosis and treatment of this condition. BPPV is the most common cause of vertigo accounting for nearly one-half of patients with peripheral vestibular dysfunction.
Inner Ear AnatomyThe inner ear is quite complex and includes both the organs for hearing (the cochlea) and balance (vestibular) (see Figure 1). Canalithiasis refers to freely moving otoconia settling within the posterior semicircular canal, causing the canal to be gravitationally sensitive. The condition is believed to arise following viral infection or trauma, but in the majority of cases it occurs in the absence of any identifiable illness or upset.
It is believed that the otoconia become dislodged due to concussive forces on the vestibular system. Persistent untreated or undiagnosed vertigo in the elderly can lead to increased caregiver burden and resultant societal costs. We believe it is crucial to educate and inform health care workers, namely physiotherapists, regarding this condition in order to reduce the amount of undiagnosed cases. Currently the primary method of diagnosis involves in-depth subjective screening, followed by physical investigations and diagnostic manoeuvres to confirm BPPV. They highly suggest asking patients questions to explore whether they experience onset of dizziness when turning over in bed and dizziness for less than 15 seconds.[12] Answering yes to either of these questions indicates a potential diagnosis of BPPV.
The patient’s eyes should be visible and examined for nystagmus, making note of the latency, duration and direction of movement. Patients may experience a reversal of the nystagmus when returning to this position and symptoms should be allowed to resolve before moving on. Traditionally, treatment included advice on avoiding movements that induced vertigo and patients were prescribed medications for symptomatic relief.[1] Currently a shift has occurred towards treatment involving manual therapy and self-management techniques taught by qualified professionals.
In a study by Oghalai et al.[7] it was found that out of a random sample of an inner-city geriatric population, 9% were found to have previously undiagnosed BPPV. Patients with BPPV demonstrate higher rates of diabetes, stroke, hypertension and vision problems.[45] Patients with pre-existing conditions, especially stroke and peripheral neuropathy (as a result of diabetes), may already have existing balance, gait and proprioceptive problems. These changes are extremely relevant in the context of the UK’s shifting demographics and ever-aging population and as physiotherapists we have an important role to play. Many of the answers can be found within this CPD package, but the reader is encouraged to use links provided to explore additional resources available on this subject. If you are still unclear on the techniques ask a colleague or supervisor for advice and guidance.
The most common cause is benign paroxysmal positional vertigo (BPPV) but other causes include Meniere’s disease and labyrinthitis. It is commonly associated with vomiting or nausea, unsteadiness, and excessive perspiration. It is the second most frequent cause of recurrent vertigo with a lifetime occurrence rate of about 1%.
As if my puny, mortal howl could bring the cyclone of a spiralling bedroom back down to earth. One tilt of my noggin in the wrong direction and I'd be gyrating on the hellish Half-Cups at the "amusement" park of my youth, tortured forever by a notorious public barf, as I spewed and staggered down a wooden ramp, grossing out the crowd. I was flooded with frustration, itching to get back to the roller-coaster ride of my writing life. With my sweaty head in his steady hands, he performed the miraculous Epley Maneuver, by bringing me into the spin and beyond it.

The vestibular section of the ear consists of the saccule, utricle and three semicircular canals (anterior, posterior and horizontal).
It contains otoconia (calcium carbonate particles) which are surrounded by a gelatinous matrix and stereociliary hairs (see Figure 2). Physiotherapy methods of diagnosis and treatment are safe, simple to administer, cost-effective, and encouraged to help relieve this burden. Through this, we aim to reduce the number of unplanned hospital admissions and falls amongst the elderly population. These methods of diagnosis have been shown to be clinically appropriate, simple to perform, and cost effective.[10] Early diagnosis of BPPV is important and may help improve quality of life for patients and reduce the risk of more serious injury. Some important aspects of the condition have been identified which should be explored to rule out other causes. Nystagmus may fatigue and reduce with repetition of the maneuver, so looking out for this symptom is important to minimize the need for repeat testing.[10] Continued communication with the patient is essential to help establish and monitor when uncomfortable symptoms of vertigo arise.
Geotropic nystagmus refers to a nystagmus pattern where the upper half of the eye is directed towards the ground.
This will help to prevent unplanned hospital admissions which are both costly for the NHS and to the patients’ quality of life.
They also found that those with unrecognized BPPV were more likely to have reduced activities of daily living scores and to have sustained a fall in the past 3 months. Once a diagnosis has been made, treatment can begin, this ensures that the patient recovers as quickly as possible, and minimizes the impact of BPPV on their life.
Now that you have a basic understanding of the anatomy, pathophysiology and current management of this condition, you are encouraged to reflect on you current role in BPPV management and consider how your own practice may be improved.
Repetitive spinning, as in familiar childhood games, can induce short-lived vertigo by disrupting the inertia of the fluid in the vestibular system. Blurred vision, difficulty speaking, a lowered level of consciousness, and hearing loss may also occur. This is when the eyes rapidly jerk to one side and then slowly find their way back to the original position. The clinician helps the patient to lie down backwards quickly with the head held in approximately 20 degrees of extension.
Between the first two bouts, I was still feeling dizzy when I leaned over to smooch my sleeping prince.
Two months later, as I type this post, it finally hits me what I learned from lying down: I needed a break.
Each of these canals plays an essential role in maintaining balance.[2]The semicircular canals are responsible for detecting rotational movement of the head. In about 5% of cases cupulolithiasis occurs, where the otoconia adhere to the cupula of the lateral semicircular canal causing it to be heavier than the surrounding endolymph. Techniques may be easily incorporated into routine physiotherapy assessment and should be considered for any patients presenting with symptoms of dizziness and vertigo.
This would ensure BPPV is diagnosed in patients who are routinely falling as a result of the condition and allow them to get the appropriate treatment, aiming to prevent future falls and unplanned hospitals admissions.
In reality, diagnosis of BPPV is relatively straightforward when patient’s history and correct diagnostic tests are performed in the physical assessment.[17] The treatment of BPPV, as described in this learning package, is also simple to perform and is a cost and time effective method of management.
It is often associated with nausea and vomiting as well as difficulties standing or walking. This extension may either be achieved by having the clinician supporting the head as it hangs off the table or by placing a pillow under their upper back.
It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds.
The typical pattern of nystagmus seen for each type of BPPV is presented in the table below.
Out of the 64 participants, over half (53.1%) had reported recurrent falls, with over 80% reporting a tendency to fall.
The impact of falls and hospital admissions resulting from BPPV is costly both in terms of healthcare bills but also on patients’ physical health and quality of life. The patient’s eyes are then observed for about 45 seconds as there is a characteristic 5-10 second period of latency prior to the onset of nystagmus. The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary.
The direction of nystagmus is different depending on location of the calcium carbonate crystals.
At present, BPPV is being undiagnosed too frequently, and is often only recognized upon admittance due to a secondary injury caused by a fall.[45] By physiotherapists having the appropriate knowledge and developing their skills in the diagnostic and treatment techniques, BPPV can be managed more effectively. If rotational nystagmus occurs then the test is considered positive for benign positional vertigo. The fluid shift lags behind movement of the head and as a result pressure is exerted on the cupula, the motion sensory receptor at the base of the canal. Appropriate intervention by physiotherapists and other healthcare professionals can help to reduce the falls associated with BPPV and as a result prevent unplanned hospital admissions. During a positive test, the fast phase of the rotatory nystagmus is toward the affected ear, which is the ear closest to the ground. The direction of the fast phase is defined by the rotation of the top of the eye, either clockwise or counter-clockwise.

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