I've been eager to write an article on Benign Paroxysmal Positional Vertigo (BPPV) for a while, especially given the success we've seen in treating it at our clinic.
With a proven success rate of approximately 80-90% using maneuvers like the Epley and Half Somersault, we specialize in precise diagnosis and targeted treatments that help patients quickly return to their daily activities. I hope this information not only aids in fostering quicker recoveries for those suffering from vertigo but also enriches our collective understanding of BPPV. Your insights and experiences are invaluable, and I look forward to your feedback.
Article Index
Diagnosis (with video demonstrations)
HINTS Exam
Dix-Hallpike Maneuver
Treatment (with video demonstrations)
Epley Maneuver
Half Somersault Maneuver
Lempert Maneuver
Deep Head Hanging Maneuver
Brandt-Daroff Exercises
Modified Epley or Half Somersault Maneuver
Introduction
What is BPPV?
Benign Paroxysmal Positional Vertigo (BPPV) is a common vestibular disorder that causes brief episodes of vertigo triggered by specific head movements. It occurs when tiny calcium carbonate crystals, called otoconia, become dislodged and enter the semicircular canals of the inner ear. This misplacement disrupts the normal functioning of sensory hair cells, sending false motion signals to the brain and resulting in a spinning sensation.
Importance of Proper Diagnosis and Treatment
Accurate diagnosis of BPPV is crucial, as it involves identifying the specific semicircular canal affected and distinguishing BPPV from other vestibular or central nervous system disorders. Misdiagnosis can lead to ineffective or harmful treatments, making precise diagnostic procedures essential. Proper treatment can quickly alleviate symptoms and greatly enhance a patient's quality of life.
Objective of the Article
This article builds on the content presented in the accompanying BPPV video series, offering a deeper exploration of diagnostic techniques, treatment options, and the underlying pathophysiology of BPPV.
Diagnosis of BPPV Vertigo
The correct diagnosis of Benign Paroxysmal Positional Vertigo (BPPV) is vital for appropriate treatment and patient care. Here, two critical diagnostic tools will be discussed: the HINTS exam and the Dix-Hallpike maneuver.
HINTS Exam
The HINTS (Head Impulse, Nystagmus, Test of Skew) exam is an indispensable triad of evaluations used to discern central from peripheral causes of vertigo or dizziness. It plays a vital role, particularly in acute scenarios, and can be more sensitive than early MRI in detecting strokes that manifest with vertigo symptoms. The components of the HINTS exam are:
1. Head Impulse
Objective: Assess the vestibulo-ocular reflex (VOR) to pinpoint potential dysfunction in the vestibular nerve.
Method:
The patient is asked to fixate on a target straight ahead.
The examiner swiftly turns the patient's head to one side.
A normal response (intact VOR) will see the eyes remain fixed on the target; an abnormal response (deficient VOR) will necessitate a corrective saccade.
Significance: A positive head impulse test is typically indicative of a peripheral lesion, such as vestibular neuritis.
2. Nystagmus
Objective: Examine the pattern of eye movements to distinguish peripheral vestibular nystagmus from central nervous system-related nystagmus.
Method:
Observe the patient's eyes for involuntary rhythmic movement.
Note the direction, amplitude, and frequency of the nystagmus in different gaze positions.
Assess whether the nystagmus is unidirectional (usually peripheral) or changes direction with gaze (usually central).
Significance: The nature of the nystagmus can provide vital clues about the underlying pathology and its location.
3. Test of Skew
Objective: Check for vertical eye misalignment, a sign that might point to a brainstem or cerebellar lesion.
Method:
The examiner covers one eye and then quickly uncovers it, observing for any corrective vertical movement in the covered eye.
The process is repeated on the other eye.
Any vertical misalignment between the eyes is noted.
Significance: A positive skew deviation may signal a central lesion and requires further neurologic evaluation.
HINTS Exam Demonstration
The HINTS Exam is used to differentiate benign peripheral conditions from a problem in the central nervous system, lesions like a stroke. HINTS stands for Head Impulse-Nystagmus-Test of Skew. Head Impulse: a test of vestibulo-ocular reflex function. A normal Head Impulse test (HIT) strongly indicates a central localization for Acute Vestibular Syndrome.
Dix-Hallpike Maneuver
The Dix-Hallpike maneuver is a diagnostic procedure specifically utilized to identify posterior canal BPPV. Its methodology involves:
Positioning the Patient: Having the patient sit upright on an examination table, with legs fully extended.
Turning the Head: Rotating the patient's head 45 degrees to one side.
Laying the Patient Down: Quickly laying the patient back, with the head hanging off the table and maintained at a 30-degree angle below horizontal.
Observing for Nystagmus: Carefully watching for nystagmus or jerking eye movements, which may confirm the presence of BPPV.
The Dix-Hallpike maneuver is indicated for patients with a history of recurrent, brief vertigo triggered by changes in head position. It assists in confirming the presence and side of posterior canal BPPV, guiding subsequent therapeutic interventions.
Dix HallPike Maneuver Demonstration
We will explore the Dix HallPike maneuver in detail and discuss how it can serve as an excellent starting point for diagnosing vertigo, especially BPPV.
Why the direction of eye movement is essential:
Identifying the Affected Canal: The direction of the nystagmus can indicate which semicircular canal has the dislodged otoconia. For example, upward and torsional (rotary) nystagmus typically indicates posterior canal involvement, while horizontal nystagmus might indicate lateral canal involvement.
Determining the Type of BPPV: The direction of eye movement may help differentiate between canalithiasis (free-floating crystals) and cupulolithiasis (crystals adhered to the cupula). In canalithiasis, the nystagmus will typically beat towards the affected ear in posterior canal BPPV, while in cupulolithiasis, it may beat towards the unaffected side.
Confirming the Diagnosis: The pattern of nystagmus can confirm or rule out other vestibular or central nervous system disorders. Specific characteristics of nystagmus (e.g., latency, duration, direction) contribute to the accuracy of diagnosis.
In summary, careful observation of the direction and characteristics of nystagmus during the Dix-Hallpike maneuver provides vital diagnostic information. It guides the clinician in understanding the underlying pathology and informs the appropriate treatment approach. Therefore, expertise in recognizing and interpreting these eye movements is a key skill for medical and MSK practitioners dealing with vestibular disorders.
Treatment Options
Successful treatment of Benign Paroxysmal Positional Vertigo (BPPV) hinges on targeted canalith repositioning maneuvers, each tailored to the affected semicircular canal. Below are descriptions of some widely used methods, including references to instructional videos.
Epley Maneuver
The Epley Maneuver is a well-established therapeutic intervention targeting Benign Paroxysmal Positional Vertigo (BPPV) of the posterior canal, the most prevalent variant of BPPV. It is a non-invasive procedure with a commendable success rate, making it an essential tool for clinicians dealing with vestibular disorders.
Initial Positioning: Start with the patient sitting upright on an examination table. Turn the patient's head 45 degrees toward the affected ear (the side causing vertigo). Lay the patient down quickly, with their head still turned, so that it hangs slightly over the edge of the table. Observe for torsional and upward-beating nystagmus, indicating that the otoconia are in the posterior canal of the affected side.
First Position - Head Turned to Affected Side: Hold this position for approximately 30 seconds or until the nystagmus and vertigo subside. This allows the otoconia to move towards the apex of the canal.
Second Position - Head Turned to Unaffected Side: Without raising the patient's head, turn it 90 degrees toward the unaffected ear. Hold for another 30 seconds, watching for changes in the nystagmus, which should follow the direction of crystal movement within the canal.
Third Position - Side-Lying Position: Have the patient roll onto the unaffected side (the side not causing vertigo), keeping the head turned towards the unaffected side at a 45-degree angle. Hold this position for 30 seconds. This maneuver helps guide the otoconia towards the exit of the affected canal.
Final Position - Sitting Up: Assist the patient to a sitting position, keeping the head turned towards the unaffected side for a few seconds, and then gradually bring the head back to the neutral forward position. Observe for resolution or significant decrease in nystagmus, indicating successful treatment.
Assessment: Assess the patient for residual symptoms and, if necessary, repeat the procedure.
The Epley Maneuver aims to guide the dislodged otoconia back into the utricle where they belong, using gravity and specific head movements. Observing the expected nystagmus at each stage can confirm that the crystals are moving as intended. This process may be repeated in subsequent sessions if needed, or even within the same session if the nystagmus and symptoms do not resolve. Careful observation, clear communication with the patient, and gentle but deliberate movements are essential for successful application of this treatment.
Eye Motion
When performing the Epley Maneuver to treat Benign Paroxysmal Positional Vertigo (BPPV) of the posterior canal, the expected nystagmus will generally have a torsional component and may beat upward towards the forehead. Here's what to look for:
Initial Dix-Hallpike Position: When the patient is laid back into the Dix-Hallpike position with the affected ear down, the nystagmus should be torsional (rotating around the visual axis) and beating upward toward the affected ear. This pattern confirms that the loose otoconia are in the posterior canal of the affected side.
During the Epley Maneuver: As you guide the patient through the different positions of the Epley Maneuver, the direction of the nystagmus may change in accordance with the movement of the otoconia within the semicircular canal. Observing these changes helps confirm that the otoconia are moving as expected.
Resolution of Symptoms: Successful completion of the Epley Maneuver should lead to the resolution of both the patient's vertigo symptoms and the nystagmus. If nystagmus persists or if an unexpected pattern of eye movements is observed, further evaluation may be required to confirm the diagnosis or to assess for other underlying conditions.
In summary, during the Epley Maneuver for posterior canal BPPV, the nystagmus should initially be torsional and upward-beating towards the affected ear. Its pattern through the maneuver and its eventual cessation can guide the clinician in the successful treatment of the condition. Understanding and recognizing this characteristic eye movement pattern is a crucial aspect of accurate diagnosis and effective treatment.
Epley Maneuver Demonstration
In this video, we will review the Epley Maneuver, a procedure used to remove a crystal that becomes lodged in the posterior semicircular canal. This maneuver is one of the effective procedures that we provide for our patients suffering from BPPV.
Half Somersault Maneuver
The Half Somersault Maneuver is another method used to treat Benign Paroxysmal Positional Vertigo (BPPV), specifically when otoconia are lodged in the posterior canal. This maneuver involves a series of positions, and understanding the eye movements can be vital to its successful execution.
Start Position (Kneeling): The patient starts by kneeling and then quickly tucks their head into a somersault position, looking upward. At this stage, you may or may not observe nystagmus, depending on the condition's severity.
Somersault Position: With the head still tucked, the patient turns their head 45 degrees towards the affected side (the side causing vertigo). If the loose crystals are in the posterior canal, you might observe torsional nystagmus, where the top of the eye beats toward the affected ear.
Side-Lying Position: The patient then rolls onto their side, keeping their head turned. The expectation would be for the nystagmus to continue or increase if the crystals are moving as intended.
Sitting Position: As the patient comes into the sitting position, the nystagmus may diminish or cease, indicating that the otoconia have moved out of the canal and back into the utricle, where they belong.
The direction and presence of nystagmus in each position of the Half Somersault Maneuver provide insight into whether the otoconia are moving as expected through the semicircular canal. Proper observation of these eye movements helps ensure that the procedure is carried out correctly and that the underlying condition is appropriately treated.
As with other maneuvers, individual variations might occur, and not all patients will display the same nystagmus patterns. Therefore, comprehensive understanding of the underlying anatomy and pathology, as well as experience in performing the maneuver, is crucial for accurate interpretation of the eye movements.
Half Somersault Maneuver Demonstration
The Half Somersault Maneuver can be an effective alternative to the Epley Maneuver. Specifically for those individuals who are not able to perform the Epley Maneuver due to physical restrictions.
Lempert Maneuver
The Lempert Maneuver, also known as the Barbecue Roll or Roll Test, is utilized to treat horizontal canal BPPV. The eye movements during this maneuver are an essential part of both diagnosis and treatment. Here’s how the eye movements manifest and how to perform the maneuver:
Identification of the Affected Canal: Start by diagnosing which ear is affected, typically through observation of horizontal nystagmus during specific positioning tests. If the fast phase of nystagmus beats towards the affected ear (geotropic nystagmus), the debris is likely in the canal; if it beats away from the affected ear (ageotropic nystagmus), the debris is likely in the cupula.
Starting Position: The patient lies supine with their head elevated to about 30 degrees. This ensures that the horizontal canal is aligned with the gravitational plane.
First Roll (towards the affected ear for geotropic nystagmus, or the unaffected ear for ageotropic): Roll the patient’s head 90 degrees to one side and observe the eyes for horizontal nystagmus. Hold for 1-2 minutes or until the nystagmus and vertigo subside. This step helps move the otoconia towards the exit of the horizontal canal (for geotropic) or dislodge them from the cupula (for ageotropic).
Subsequent Rolls: Continue rolling the head in the same direction in 90-degree increments, waiting at each position until the nystagmus and vertigo subside. The direction and persistence of nystagmus will guide the progression of the maneuver.
Final Position - Sitting Up: After the final roll, assist the patient to a sitting position.
Assessment: Assess for resolution of nystagmus and symptoms. If necessary, repeat the procedure or consider other maneuvers based on the individual’s response.
The direction and persistence of the horizontal nystagmus during the Lempert Maneuver are critical for determining the affected side and whether the otoconia are in the canal or the cupula. Understanding and observing these eye movements guide the direction of the rolls and the success of the treatment.
It’s important to note that the Lempert Maneuver is generally reserved for horizontal canal BPPV and may not be effective for other forms of BPPV. Individual variations might occur, and not all patients will display the same nystagmus patterns, so careful evaluation and experience in performing the maneuver are essential.
Lempert Maneuver Demonstration The Lempert Maneuver (Barbecue roll) is a series of steps used as a non-invasive way to treat the vertigo associated with Benign Paroxysmal Positional Vertigo (BPPV).
Deep Head Hanging Maneuver
The Deep Head Hanging Maneuver is another method used to treat Benign Paroxysmal Positional Vertigo (BPPV), specifically targeting the posterior canal. Eye movement during this maneuver is essential for diagnosis and the determination of the effectiveness of the treatment.
Here's how the eye movement manifests during the Deep Head Hanging Maneuver:
Identification of the Affected Canal: Diagnosis of posterior canal BPPV is typically determined by observing torsional and upward-beating nystagmus during positioning tests like the Dix-Hallpike Maneuver. The direction of the torsional component indicates which ear is affected.
Starting Position: The patient is seated on an examination table. The examiner stands behind the patient to observe eye movements and support the head.
Head Hanging Position: The patient's head is extended backward to hang over the edge of the examination table, with the neck supported by the examiner. The head is held in this deep hanging position for about 30 seconds. The examiner observes for torsional and upward-beating nystagmus, confirming the dislodged otoconia's movement within the affected posterior canal.
Returning to the Sitting Position: The patient is slowly brought back to the sitting position, with the examiner continuing to observe eye movements. Some patients may experience transient nystagmus in the opposite direction as the otoconia return to the utricle.
Assessment: Assess the patient for any residual symptoms. Repeat the procedure if necessary.
The Deep Head Hanging Maneuver's success relies on the gravity-driven movement of otoconia back into the utricle, utilizing a more extreme head position than other maneuvers. Eye movements, specifically torsional and upward-beating nystagmus, confirm the otoconia's presence in the posterior canal and guide the procedure.
The observation of eye movement is essential not only for determining the affected side but also for confirming the effectiveness of the treatment. As with other maneuvers for BPPV, the skilled interpretation of nystagmus patterns by an experienced practitioner ensures that the correct diagnosis is made, and the most effective treatment is administered.
Deep Head Hanging Maneuver Demonstration
The Deep Head Hanging Maneuver is used to treat a type of benign vertigo called benign paroxysmal positional vertigo (BPPV).
Treatment Frequency Recommendations
Initial Phase:
Manual Therapy:Â 1-2 sessions per week, based on symptom severity.
Home Exercises:Â Daily practice of Brandt-Daroff, Modified Epley, or Half Somersault Maneuvers under guidance.
Response Assessment (After 2 Weeks):
Positive Response:
Manual Therapy:Â Reduce to 1 session per week or bi-weekly. If full resolution of condition discontinue treatment.
Home Exercises:Â Continue daily, adjust as needed.
Persistent Symptoms:
Manual Therapy:Â continue with 1-2 sessions per week, based on symptom severity.
Home Exercises:Â Continue daily, adjust as needed.
Response Assessment (Weekly):
Positive Response:
Manual Therapy:Â Reduce to 1 session per week or bi-weekly. If full resolution of condition discontinue treatment.
Home Exercises:Â Continue daily, adjust as needed.
Persistent Symptoms:
Refer: If after 3 to 4 weeks of treatment for BPPV with no significant response, it’s advisable to refer the patient to a specialist such as an otolaryngologist (ENT) or a neurologist.
Home Care Exercises
The management of Benign Paroxysmal Positional Vertigo (BPPV) extends beyond the clinical environment into a patient's daily life. Tailoring personalized exercises and self-care routines is pivotal in controlling and potentially averting recurrent episodes.
Specific exercises, particularly in chronic or repeated BPPV cases, may alleviate symptoms and act as preventative measures:
Brandt-Daroff Exercises
These exercises are particularly useful for those suffering from BPPV and can be performed at home to alleviate symptoms. The procedure is as follows:
Sitting Position: Start by sitting on the edge of the bed or couch, legs dangling, with a pillow placed behind you.
Lying Down: Turn your head 45 degrees to one side (the affected side if known), then quickly lie down on the opposite side, letting the pillow support your shoulders but not your head.
Hold Position: Maintain this position for 30 seconds or until vertigo subsides.
Returning to Sitting: Sit back up, pause for 30 seconds, allowing any dizziness to dissipate.
Repeat: Repeat the process on the opposite side.
Session: Conduct a set of 5 repetitions on each side, twice a day.
Note: It is normal to feel dizzy during these exercises. Always consult with a healthcare provider before starting them and possibly have a support person present.
Modified Epley or Half Somersault Maneuver
These are more complex maneuvers that can be adapted for home care under professional guidance. Here's a step-by-step guide:
Modified Epley Maneuver
Sitting Position: Sit upright on the bed, legs extended.
Turn Head: Turn the head 45 degrees towards the affected ear.
Lie Back: Quickly recline, keeping the head turned, allowing it to hang slightly off the bed's edge.
Hold Position: Wait for 30 seconds to 2 minutes, or until vertigo symptoms cease.
Rotate Head: Turn the head 90 degrees to the opposite side without raising it.
Roll onto Side: Roll onto the side in the direction the head is turned, looking downward.
Sit Up: Slowly rise to a sitting position.
Half Somersault Maneuver
Kneel Down: Kneel and then quickly tip the head upward and back.
Forward Tumble: Tumble forward into a somersault position, with the chin tucked toward the knee.
Turn Towards Affected Ear: Turn the head 45 degrees toward the affected ear.
Hold Position: Wait until vertigo symptoms subside.
Raise Head: Raise the head to a back-level position, keeping it turned.
Sit Back: Sit back quickly, keeping the head turned to the shoulder.
Vertigo: How We Can Help
Our clinic offers highly effective treatment for Benign Paroxysmal Positional Vertigo (BPPV), with a success rate of approximately 80-90% using maneuvers like the Epley and Half Somersault. We specialize in precise diagnosis and targeted treatments, ensuring you receive the right care from the start, so you can quickly return to your daily activities without the frustration of recurring symptoms.
In addition to in-clinic treatments, we provide you with easy-to-follow home exercises to sustain your progress and prevent recurrence.
Our comprehensive approach, combined with our high success rates, ensures that you receive personalized care tailored to your unique needs, helping you regain control of your life and overcome BPPV for good.
References
Bhattacharyya, N., et al. (2017). Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology–Head and Neck Surgery, 156(3_suppl), S1-S47. DOI: 10.1177/0194599816689667.
Fife, T. D., et al. (2008). 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, 70(22), 2067-2074. DOI: 10.1212/01.wnl.0000313378.77444.ac.
Hilton, M. P., & Pinder, D. K. (2014). The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews, (12). DOI: 10.1002/14651858.CD003162.pub3.
von Brevern, M., et al. (2015). Epidemiology of benign paroxysmal positional vertigo: a population based study. Journal of Neurology, Neurosurgery & Psychiatry, 86(7), 708-711. DOI: 10.1136/jnnp-2014-309883.
Kim, J. S., & Zee, D. S. (2014). Clinical practice. Benign paroxysmal positional vertigo. The New England Journal of Medicine, 370(12), 1138-1147. DOI: 10.1056/NEJMcp1309481.
Baloh, R. W., et al. (1987). The Dizzy Patient: Postural Strategies for Management. The Physician and Sportsmedicine, 15(4), 109-116. DOI: 10.1080/00913847.1987.11709169.
Helminski, J. O., et al. (2010). Strategies to prevent recurrence of benign paroxysmal positional vertigo. Archives of Otolaryngology–Head & Neck Surgery, 136(4), 381-386. DOI: 10.1001/archoto.2010.31.
Hanley, K., & O'Dowd, T. (2002). Symptoms of vertigo in general practice: a prospective study of diagnosis. The British Journal of General Practice, 52(482), 809-812.
Froehling, D. A., et al. (1991). The Canalith Repositioning Procedure for the Treatment of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial. Mayo Clinic Proceedings, 66(7), 681-695.
Parnes, L. S., & Agrawal, S. K. (2003). Diagnosis and Management of Benign Paroxysmal Positional Vertigo (BPPV). CMAJ, 169(7), 681-693.
Anagnostou, E., et al. (2015). Diagnosis, Pathophysiology and Treatment of BPPV: The Apogeotropic Variant. Clinical Neurology and Neurosurgery, 139, 59-64. DOI: 10.1016/j.clineuro.2015.09.014.
Korres, S., & Riga, M. (2010). Treatment of BPPV with the Easy Dizzy Physical Therapy Rehabilitation Device: A Pilot Study. Otolaryngology–Head and Neck Surgery, 142(3), 429-433. DOI: 10.1016/j.otohns.2009.12.007.
Epley, J. M. (1992). The Canalith Repositioning Procedure: For Treatment of Benign Paroxysmal Positional Vertigo. Otolaryngology-Head and Neck Surgery, 107(3), 399-404.
Honrubia, V., et al. (1999). Paroxysmal Positional Vertigo Syndrome. The American Journal of Otology, 20(4), 465-470.
Fife, T. D., & Iverson, D. J. (2008). Practice Parameter: Therapies for Benign Paroxysmal Positional Vertigo (An Evidence-Based Review). Neurology, 70(22), 2067-2074. DOI: 10.1212/01.wnl.0000313378.77444.ac.
Brandt, T., et al. (1994). How to Treat the Atonic Component of Paroxysmal Positional Nystagmus with the Semont Maneuver. Archives of Otolaryngology-Head & Neck Surgery, 120(10), 1107-1111.
Foster, C. A., & Ponnapan, A. (2011). A Simplified Diagnostic Approach to Dizziness and Vertigo: The Three-In-One Questions. International Journal of Otolaryngology, 2011, Article ID 281319. DOI: 10.1155/2011/281319.
Herdman, S. J., & Whitney, S. L. (2000). Treatment of the Patient with Benign Paroxysmal Positional Vertigo. Physical Therapy Practice, 9, 31-41.
Wolf, M., et al. (1999). Long-term results of the Semont maneuver for benign paroxysmal positional vertigo. Archives of Otolaryngology-Head & Neck Surgery, 125(6), 629-633.
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DR. BRIAN ABELSON, DC. - The Author
With over 30 years of clinical practice and experience in treating over 25,000 patients with a success rate of over 90%, Dr. Abelson created the powerful and effective Motion Specific Release (MSR) Treatment Systems.
As an internationally best-selling author, he aims to educate and share techniques to benefit the broader healthcare community.
A perpetual student himself, Dr. Abelson continually integrates leading-edge techniques into the MSR programs, with a strong emphasis on multidisciplinary care. His work constantly emphasizes patient-centred care and advancing treatment methods. His practice, Kinetic Health, is located in Calgary, Alberta, Canada.
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