The medical field loves abbreviations, with BPPV being one for a particular tongue twister. Benign paroxysmal positional vertigo, try saying that three times fast! It may be a mouthful, but it is an exact description of this headspinning condition.
- benign = not malignant
- paroxysmal = sudden, intense onset of short duration
- positional = change of position
- vertigo = dizziness/imbalance/spinning/disequilibrium
Which is the perfect description of the situation, although if you have ever experienced BPPV you may like to argue the use of the word benign. It isn’t malignant, but it is very scary!
Repositioning manoeuvres are quick and effective at curing BPPV completely, while residual dizziness can be treated with vestibular rehabilitation therapy.
What is my vestibular system?
Your body’s gyroscopes are snugly embedded in your temporal bones. Your temporal bones, one left and one right, are part of your skull in your hairline above and around your ear. You may have heard the phrase “temporal headache” to describe pain in this area. Deeper within the bone, tucked into its own special compartment or vestibule, sits your vestibular apparatus.
The hard bony labyrinth protects the soft membranous labyrinth, in the same way as the skull protects the brain. The bony labyrinth is filled with perilymphatic fluid that has a similar composition to cerebrospinal fluid, while the membranous labyrinth is filled with endolymph, with a similar composition to intracellular fluid. These different recipes of fluid result in different viscosities, which is important for the functioning of your gyroscopes.
You have five organs that sense movement and body position on each side, three semicircular canals (SCC) and two otoliths.
- posterior SCC
- anterior SCC
- horisontal/lateral SCC
- utricle
- saccule
These organs communicate with your brain via your vestibulocochlear nerve, CN VIII.
What does my vestibular apparatus do?
Balance is dependent on your eyes, body and ears, like a tripod. How the brain interprets the sensory information it receives from sight, proprioception and the vestibular apparatus determines if you can pirouette or land steady from a back flip.
Your semicircular canals detect changes in velocity. These three canals are at right angles to one another and communicate with the opposing SCC of the opposite side. That means your right posterior SCC communicates with your left anterior SCC. They can be described as the x,y and z axes of a 3D graph. Nerve impulses are generated when hair cells at the base of the semicircular canal, the ampulla, are deflected because of the movement of endolymph, almost like seaweed in a current.
The otoliths detect changes in linear acceleration and gravity. Your utricle relays the change of linear speed, like the movement in a car. While your saccule detects gravitational change in an elevator. This phenomenon also works with hair cell deflection, but less so in a hydrodynamic principle. Your two otoliths still have to relay information from a 3-dimensional world. Because force = mass x acceleration, otoconia solves this problem. Calcium carbonate crystals, otoconia, provide the mass for this equation. The otoconia lie embedded in the macula on top of the hair cells of the otoliths. Head movement, like nodding yes/no or side to side, is the acceleration. The angles and interplay between the utricle and saccule’s hair cell deflection can relay information in all 3 dimensions!
You have experienced this in the real world: once you have reached a steady speed, in a car, plane or elevator, the deflection of hair cells stops and you are not aware of the movement anymore, only when the speed of travel changes again.
What happens with BPPV?
When otoconia crystals become dislodged from the macula of the otoliths, they can travel into one of the semicircular canals. This wreaks havoc with the endolymphatic fluid movement within the affected canal and causes a mismatch of the communication pairs. So if your right posterior canal has an otoconia moving within, and you roll onto your right side in bed, the crystal influences the movement of endolymph on that side. Your brain gets normal messages from the left anterior canal, but conflicting information from the right posterior canal.
Your vestibular ocular reflex (VOR) is stimulated in an attempt to stabilise your sight, because your brain thinks you are moving. This is why your loved ones may see your eyes jumping (nystagmus) during these attacks.
Causes of BPPV
- head trauma, like a concussion
- labyrinthitis, viral infection of labyrinth
- ischaemia of anterior vestibular artery
- vestibular neuritis, infection of vestibular nerve
- incidence higher in elderly
- 50% idiopathic and we don’t know why it happened
Canal repositioning manoeuvres are 90% successful with a 1.25 treatments
Do I have BPPV?
Due to the frightening intensity of vertigo, plus the very real risk of vomiting, these are just questions you can answer to determine if BPPV may be causing your vertigo.
- Does your vertigo feel like your environment is spinning?
- Is your vertigo brought on by head movement?
- Does rolling over in bed cause your vertigo?
- Has getting up from lying down ever triggered your vertigo?
- Does bending down or looking up ever cause your vertigo?
- Are your vertigo attacks less than a minute long?
If you answered yes to two of these questions your vertigo may be caused by BPPV.
How severe is my vertigo?
The most extreme risk of BPPV is leaving it untreated for a long time. Not because it can cause any other structural damage or “get worse”, but because it will influence your behaviour. The more often an attack occurs, the more fear you will have of certain movements and situations.
Horisontal canal BPPV is worse that posterior canal BPPV, because it triggers more autonomic symptoms, like nausea. It is trickier to diagnose due to the direction of the nystagmus.
You could be feeling better after a single consultation.
Diagnosis of BPPV
Physiotherapy diagnosis
Our physiotherapists can identify if any central pathology is causing your symptoms, with visual and balance screening. Or is your vertigo caused by a different structure within the vestibular apparatus?
We make use of a bedside evaluation, which means all tests are done in the consultation room by your therapist or yourself.
To confirm a BPPV diagnosis, you need to undergo the Dix-Hallpike, side-lying and lateral body position tests. This is your physiotherapist assisting you to lie down and get back up, like you would to get in and out of bed. If your vertigo is caused by BPPV you will experience a short, intense attack during the treatment as we determine the direction of your nystagmus to identify the affected SCC.
The direction of your nystagmus indicates the laterality of your BPPV.
Audiology balance testing
This specialised field of audiology includes multiple tests that may take between 2 – 3 hours to complete and include:
- videonystagmography (VNG)
- computerised dynamic posturography (CDP)
- vestibular evoked myogenic potential (VEMP)
- and video head impulse testing (vHIT)
This is not needed to diagnose BPPV, but determine the cause of longer lasting vertigo attacks.
MRI
An MRI scan can image all of the structures in your brain, including the vascular supply. This is a costly image that can only be ordered by a specialist. If we suspect a central cause for your vertigo, you will be referred to a neurologist to get the necessary evaluation and care.
This is not necessary to confirm a BPPV diagnosis.
Why is my vertigo not going away?
Your vertigo attacks will continue as long as otoconia move within a semicircular canal (canalithiasis) or are stuck to the cupula (cupulolithiasis). These short, intense attacks are caused by the movement of the otoconia. You need to be treated with the correct repositioning manoeuvre to solve the problem.
Vertigo of lower intensity and longer duration are caused by a vestibular mismatch or hypofunction. Disequilibrium is used to describe this feeling of getting of a boat on your sea legs. Vertigo caused by VOR mismatch or oscilopsia, where you struggle to focus on a moving object or feel nauseous after you looked at moving objects can be treated with vestibular rehabilitation therapy. These exercises are very dose specific and you need an experienced therapist to monitor and progress your program as your symptoms improve.
Problems we see when patients come to us with BPPV
Symptoms
Vertigo is not a diagnosis, it is a symptom. You need to treat the root cause.
Diagnosis
Many people are diagnosed with BPPV as the cause of their vertigo when it is not. Many practitioners are only familiar with the Epley manoeuvre and can therefore only treat the posterior semicircular canal.
Migration of otoconia
Repositioning manoeuvres can cause migration of crystals to different canals, solving one problem only to cause a different problem. How the semicircular canals are orientated makes the horizontal canal “susceptable” to receiving the otoconia that have been moved from the posterior canal. This is a common risk and easily managed by a skilled vestibular physiotherapist.
Physiotherapy BPPV treatment
Physiotherapy is the treatment of mechanics related to movement and the programming of movement fluidity. We think like engineers but understand how a movement dysfunction can influence one’s quality of life. With vestibular rehabilitation, we aim to reprogram your brain and the vestibular apparatus’s communication and sensory processing.
1st Phase of BPPV treatment: Canal Repositioning Manoeuvre (week 0 – 1)
During your first consultation, we aim to identify the laterality and canal of your BPPV. Once this is established, your physiotherapist will do the repositioning manoeuvre (CRM) required and re-check. You should immediately feel a difference in the intensity of your vertigo with the re-test. You may need another round of the same manoeuvre or a different manoeuvre entirely. A maximum of 3 rounds of the CRM you need will be done during your first consultation.
There is no evidence to suggest that doing this manoeuvre daily will prevent you from ever experiencing vertigo again. If you feel comfortable with the sequence of the repositioning manoeuvre, you can repeat it no more than 3 times a day until your follow up consultation.
2nd Phase of BPPV treatment: VRT integration (week 2 – 4)
Once your crystals are repositioned, we will do different types of exercises to integrate the sensory information you are receiving and encourage the correct output. This gradual exposure may be walking with head turns or doing head movements while balancing to enable you to drive, go shopping or back to boot camp.
This phase of treatment is different for everyone as we custom your program to your unique needs and activity levels. You will still need to avoid the treadmill, stationary bikes or moving walkways at the airport for the sensory conflict.
Healing time for BPPV
Great news! You will immediately feel better once the correct repositioning manoeuvre has been done! This means no more intense attacks with change of position.
The unsteady or dysequilibrium may persist for a few weeks afterwards, and will be eased by your VRT home exercises.
Most people feel relieved once they understand the cause of their symptoms, and therefore much better than before while procrastinating and catastrophising.
Other forms of benign paroxysmal positional vertigo treatment
Your GP or ENT may prescribe the following medication to ease your symptoms:
- anti-emetic medication to alleviate nausea/vomiting
- motion sensitivity medication to reduce dizziness intensity
- (cortisone and anti virals are used for vestibular neuritis and not needed in BPPV treatment).
You may be referred for balance testing to a specialised audiologist to assess your balance in different scenarios.
Neuro optometry evaluation may be needed if you have suffered from a traumatic injury
Is surgery an option for vertigo tretament?
No, surgery is not used in the treatment of BPPV.
There are different surgical options for many other causes of vertigo, but it is not necessary for the treatment of BPPV.
What else could it be?
- Vestibulopathy
Vestibular hypofunction from an uncompensated neuritis or labyrinth concussion will cause lower grade vertigo for longer periods.
- Meniere’s disease
This condition causes vertigo, intense attacks that last for minutes to hours, hearing loss, ear fullness and tinnitis.
- Labirynth concussion
Vertigo caused by a traumatic injury, like a fall or accident, can last hours to days.
- Central pathology
Dizziness caused by a brain injury is a medical emergency and needs immediate attention. If you experience headache, struggle to speak or notice facial paralysis head straight to the emergency room.
- Pharmacological interaction
Many medications can cause dizziness due to the effect on your blood pressure or heart rate, make sure to have your list of chronic medications for your health care provider.
Also known as
- otolithiasis
- moving inner ear crystals
- posterior canal canalithiasis
- anterior canal canalithiasis
- horisontal canal canalisthiasis
- horisontal canal cupulolisthiasis
- benign positional vertigo
