Understanding Benign Paroxysmal Positional Vertigo

Ever have the sensation that the room is spinning? Worried about staying upright because of feeling off balance? Dizziness can be multifactorial and unpacking that big grey box can be a difficult task. Things that can make people dizzy are medications, hypoglycemia, rapid change in blood pressure or volume, anxiety, anemia, central nervous system insult, visual motion sensitivity, cervical pain/whiplash, or impairment in the inner ear are a few. Dizziness can also be described as vertigo, according to Dorland’s Medical Dictionary, an illusion of movement.

Physical therapy can be helpful with recovering and managing vertigo. Vestibular therapy is value added for patients with peripheral disorders like, an inner ear hypofunction, Meniere’s Disease, Benign paroxysmal positional vertigo (BPPV), and more central disorders like vestibular migraine, persistent postural perceptual dizziness, post-concussion syndrome, and both central and peripheral, age-related dizziness and imbalance. 

Our balance is simplified and maintained by three primary systems: vision, somatosensory/proprioception, and the vestibular system. 1 in 3 adults over the age of 40 will have some degree of vestibular dysfunction otherwise known as a problem in the inner ear.  The vestibular system detects linear and angular acceleration. When the body moves endolymph fluid moves in tiny canals in your skull and trigger a response to the brain of acceleration. When there is disruption in the inner ear, the result is a mismatch of information in central processing centers. There can be issues with gaze stability, postural stability (balance), orientation in space and cerebral perfusion (autonomic nervous system).

This post aims to give readers a basic understanding of the complex vestibular system, and explain one type peripheral dysfunction, BPPV, and a plan of action for management.

Benign Paroxysmal Positional Vertigo (or BPPV) is currently the most common cause of vertigo. The sudden onset of vertigo occurs because calcium carbonate crystals (otoconia) become dislodged from there normal gelatinous matrix to help sense gravity and become free floating in the semicircular canals. When there is position change or movement, the otoconia move and vertigo presents.

Typical Presentation of BPPV: (Von Brevern, 2013)

• Brief attacks of vertigo, lasting 10 to 60 seconds

• Provoked by head movements 

• Turning over in bed

• Lying down

• Tilting head up or

down (bending forward)

Etiology: (Fife, 2012)

• Most cases are idiopathic

• Can occur with or after other conditions affecting inner ear-

• Vestibular neuritis

• Meniere’s disease

• Idiopathic sensorineural hearing loss 

• Head trauma

Treatment:

When dealing with vertigo it is highly recommended to be diagnosed and treated by a certified vestibular rehab therapist, for a full evaluation. Best practice if confirmed BPPV is to use Canalith Repositioning Maneuvers (CRM) after determining which type of BPPV is present and which canal is affected. These maneuvers involve moving the body and head to utilize gravity to shift the otoconia out of canals back to the original chamber. Some believe BPPV will spontaneously resolve (which is possible) or they can perform canalith repositioning independently, but this is not recommended because the incorrect positioning could be used. With an ineffective maneuver, vertigo will persist, and balance and function will continue to be compromised.

Why Treat?:(Oghalai et al., 2000; von Brevern et al., 2007)

• Older patients with BPPV experience a greater incidence of falls, depression and impairments of daily activities

• Almost 86% of patients will suffer some interrupted daily activities and lost days at work due to BPPV 

• 68% of patients with BPPV will reduce their workload

Beyond managing vertigo with CRM, balance needs to be assessed and treated after bouts of BPPV.  Research has shown postural abnormalities present up to 1 month after repositioning has been effective (Di Girolamo, 1998). BPPV is a condition with recurrence rates as high as 50% within 5 years (Fife 2008). Sim et al, 2019, found at 12 months, 52.9% of patients continued to feel unsteady, after vertigo resolution

Bottomline- BPPV is a treatable inner ear dysfunction, as are probable recurrences of BPPV, with specialized help in vestibular rehab to focus on a combination of CRM and balance to achieve safe optimal functioning. 

If you or someone you care about is experiencing the above symptoms, please reach out for a formal evaluation by one of our trained professionals.

Written By: Erin Williams, PT, DPT

References:

Shigeno K, et al. Benign paroxysmal positional vertigo and head position during sleep. J Vestib Res. 2012: Jan 1;22(4):197.

Von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D, Newman- Toker D. Benign paroxysmal positional vertigo: Diagnostic criteria. J Vestib Res 2015;25:105-17.

Fife TD. Positional dizziness. Continuum (Minneap Minn). 2012 Oct;18(5 Neuro-otology):1060-85.

Fife TD, et al. Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): Report on the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067-74.

Von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D, Newman- Toker D. Benign paroxysmal positional vertigo: Diagnostic criteria. J Vestib Res 2015;25:105-17.

Di Girolamo et al. Postural control in BPPV before and after recovery. Acta Otolaryngol. 1998. 118(3):289-93.

Sim E, Tan D, Hill K. Poor Treatment Outcomes Following Repositioning Maneuvers in Younger and Older Adults with Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis. J Am Med Dir Assoc. 2019 Feb;20