By Karolina Kozlova, PT, DPT, Neurologic Clinical Specialist
What is BPPV?
Benign paroxysmal positional vertigo (BPPV) is an inner ear disorder where small crystals of calcium carbonate break loose and fall into another area within the balance canals. This causes short periods of vertigo and imbalance that are associated with a change in head position with respect to gravity. Symptoms most commonly occur when lying down, turning over in bed, looking up or bending over. Symptoms can include feeling like the world is moving (even if you are still), nausea/vomiting, sweating, and abnormal eye movements.
What causes BPPV?
Most cases of BPPV occur for no reason. They can sometimes be associated with migraines, trauma, diabetes, osteoporosis, other inner ear problems or with lying in bed for prolonged periods of time (post-surgery precautions, illness, etc.)
The vestibular system is a small organ in your inner ear that helps keep your balance. It is made up of three semicircular canals and two otolithic organs called the utricle and saccule – the entire system is connected by inner ear fluid called endolymph and a nerve that communicates with the brain.
The utricle and saccule have receptors that are loaded with tiny calcium crystals which help detect small movements of your head. If at any point these crystals become loose, they will float into the semicircular canals via the endolymphatic fluid.
Every time you move your head in a certain position, the crystals will move within the canals and irritate the balance organ causing vertigo and/or imbalance.
Diagnosis/functional limitations summary
BPPV is diagnosed with positional testing, specifically the Dix-Hallpike and Roll tests. These exams involve observing the eyes for nystagmus (jumping of the eyes) with the head and body positioned in specific ways. Once both ears have been tested, the doctor decides which canal the crystals are in and will perform a “particle repositioning maneuver” to put them back into their original spot.
Recommended activity levels/Precautions/Research
Research shows that the repositioning maneuver works 80-90% of the time on the first visit if performed 2+ times by the therapist. However, up to 20% of patients require follow-up visits for successful resolution. It’s recommended that after treatment, strenuous activity, or lying flat should be avoided for the rest of the day. The next day, you should resume your routine activities and move your head normally to help you return to baseline.
BPPV is more common in elderly populations putting them at a higher risk for falls. There is also a higher re-occurrence rate if you have had BPPV in the past and/or have experienced trauma. Evidence has also shown that BBPV can resolve on its own within 2-3 weeks, however, symptoms will continue if crystals are out of place.
Types of exercises that will be addressed with therapy
Repositioning maneuvers (getting the calcium crystals back in place) will be performed during your treatment. Even with successful treatment, slight to moderate dizziness can persist. If you have residual dizziness with positional changes, your therapist may give you Brandt-Daroff exercises for home to help your brain habituate to those positions. Additionally, if imbalance and unsteadiness persist once the crystals are back in place, your therapist may prescribe balance activities to help “re-train” the way your brain organizes movements.
Summary of progression/therapy expectations/outcomes
After treatment, you may feel dizzy, nauseous, or have difficulty with balance – this is normal. The therapist might ask you to sit quietly and let the inner ear system “settle down” between treatments and to avoid any quick head movements or head tilts up/down. As mentioned above, treatment is usually successful with 1-2 treatments. Occasionally more treatment will be needed, especially if there is multi-canal involvement. Once BPPV has resolved, your symptoms subside and balance returns, there is no further need for therapy unless BPPV reoccurs.