What to Know About BPPV Treatment

It’s 10:00 AM, sunlight is streaming into your bedroom, and you roll over to start another beautiful day. But as you roll over, the whole world starts spinning. A change in head position that results in dizziness is characteristic of a condition called Benign Paroxysmal Positional Vertigo, or more commonly referred to as “BPPV”. BPPV and the horrible feeling of dizziness that comes with it, unfortunately, is not uncommon amongst older adults, however, many times, it goes undiagnosed and untreated. This article will explain BPPV, how a physical therapist can test for it, and BPPV treatment.

The Organs of the Vestibular System

BPPV is actually a dysfunction of the vestibular system, which is one of the three components that contribute to having proper balance (for more information on the components of balance, see my article here).

The five major organs of the vestibular system live in the inner ear:

1. Utricle
2. Saccule
3. Anterior Semicircular Canal
4. Posterior Semicircular Canal
5. Lateral (or Horizontal) Semicircular Canal

The utricle and saccule, also referred to as “otolith organs,” respond to gravity. They detect changes in linear acceleration and head position. Think jumping up and down, or running forward or backward. The otolith organs detect changes in speed, not changes in direction.¹

The three semicircular canals sense rotational acceleration. Think of rolling over in bed, or riding a rollercoaster. The canals detect changes in speed and changes in direction. ^1,2

In order to be balanced, we need our vestibular system to be able to detect linear and rotation acceleration properly.²

How Do The Organs Detect Changes in Speed and/or Direction?

Within the utricle and saccule hair cells that are embedded in a membrane. On top of those hair cells are carbonate crystals, called otoconia (“otoliths” in the photo above), which basically add weight to the hair cells.

When we tilt our head, or are moving in a linear path (forward/backward, upward/downward) the otoconia help provide the inertia for the hair cells to move. This sends a signal to the brain, allowing the brain to process where we are in space.

The semicircular canals are filled with fluid, called endolymph, and each has a endolymph-filled sac on their ends, which is filled with sensory hair cells, called the cupula. When our heads rotate or we are being sped around a curve on a rollercoaster, the endolymph moves, causing the the cupula to move accordingly. This, once again, sends a message to the brain, so it can process where we are in space.

The combination of the otolith organs and semicircular canals working properly allow for us to move throughout our days without even thinking about it.

The problem becomes when these two systems get disrupted.

What Causes BPPV?

With BPPV, a crystal (otoconia) that normally lives on top of the hair cells in the otolith organs gets dislodged and makes its way into the semicircular canals.

This changes how the cupula can interpret rotational changes.

When the crystal is in one of the canals, the endolymph now has an additional mass within it, which changes how it interacts with the cupula.

This causes confusion in the signal sent from the cupula to the brain. The brain then can’t interpret the change in space, and dizziness occurs.

If you’ve had BPPV and been told by a healthcare provider “It’s because you have crystals in your ears,” this is what they were talking about. The thing is, everyone has crystals in their ears, but what is occurring with BPPV is that the crystals are in the wrong place.

Typically, a crystal in one ear gets dislodged and travels into a canal. Dizziness generally occurs when turning towards the side that’s impacted.

What are the Symptoms of BPPV?

Symptoms do vary from person to person, however dizziness with positional change is very common with BPPV.

Additionally, those with BPPV may experience:

• Nausea
• Lightheadedness
• Feelings of imbalance
• Vomiting³

Is All BPPV the Same?

Although the symptoms may be the same or similar, the specific type of BPPV one has depends on which canal the crystal falls into.

BPPV is characterized by which semicircular canal the crystal (otoconia) is located in.

The most common type of BPPV is posterior canal BPPV⁴, which means the dislodged otoconia is in the posterior canal.

Another term used for this type of vertigo is “top shelf vertigo” because if someone has posterior canal BPPV and tries to look up at the top shelf in the grocery store they will experience dizziness.

Those with posterior canal BPPV may still experience dizziness when they turn towards the affected side and when looking up.

Since the posterior canal is the lowest (see picture above), it makes it the prime location for a dislodged crystal to fall down into. Usually, it won’t come out on its own, so dizziness does not just sporadically subside without treatment.

Where Else Can the Crystal End Up?

The anterior canal is most unlikely place for an otoconia to travel to and stay in because of its position within the ear.

Following posterior canal BPPV, the next most common type is horizontal canal BPPV.

Due to the location of the lateral/horizontal canal, otoconia may travel into this semicircular canal and fall back out of it spontaneously, which is why it’s not as common as posterior canal BPPV.

For horizontal canal BPPV, the otoconia is in the horizontal canal, and once again, changes in position lead to dizziness.

Canalithiasis Vs. Cupulolithiasis

In addition to where the crystal is located, BPPV is further classified as canalithiasis (can-al-oh-lith-eye-uh-sis) or cupulolithiasis (cue-pew-low-lith-eye-uh-sis).

Canalithiasis occurs when the otoconia remains in the semicircular canals. This is what more commonly occurs in BPPV.

Cupulolithasis is when the otoconia gets stuck on the cupula of one of the canals.

The type of BPPV treatment is determined based on whether one has cupulolithiasis or canalithiasis.

Is BPPV the Cause of All Vertigo?

No! Vertigo may be something benign like BPPV, or it could mean something more serious.

That’s why it’s very important to report feelings of dizziness/lightheadedness to your healthcare provider and get a complete screen.

Why Do Older Adults Need to Be Aware of BPPV?

As we age, these crystals seem to dislodge more easily.

This is why we commonly see BPPV in the older adult population.

However, there are other changes that occur with aging, such as orthostatic hypotension (getting lightheaded upon standing up too quickly), which can be misattributed to the dizziness or lightheadedness.

Also, many times individuals with vertigo don’t realize BPPV treatment exists, so they brush it off as “just a part of life.” It’s important to note that dizziness does not have to be part of life and many times something can be done to help.

Ask your physical therapist or primary healthcare provider specifically about getting screened for BPPV, because if BPPV is suspected, it can be treated.

How Do Physical Therapists Screen for BPPV?

Check out this video HERE to see all the screenings and treatment approaches for BPPV.

When a client reports dizziness due to a change in head or body position, a physical therapist will likely screen for BPPV.

To do this, a PT usually performs what’s called a Dix-Hallpike maneuver on the patient.

Dix-Hallpike:

1. The client is sitting up with legs in front of them on a treatment table/mat/bed.
2. The PT turns the clients head 45 degrees towards the side that appears to be causing the dizziness.
3. Keeping the head turned in that direction, the PT then lowers the client down to a supine position (lying on their back) with their head over the side of the treatment table.
4. The client is instructed to keep their eyes open as the PT looks for nystagmus (bouncing movement of the eyeballs indicating vertigo).
5. If nystagmus occurs, the PT times how long the vertigo lasts before it subsides.
6. If BPPV is suspected, based on the direction and duration of the nystagmus, the therapist can move on to the treatment.

Another test that can be done is called the Head Shake Test.

Head Shake Test:

1. The client is supine on a treatment table/bed.
2. The client closes their eyes and the PT places one hand on each side of the client’s head.
3. The therapist then moves the client’s head quickly from side to side while client’s eyes remained closed.
4. PT stops the quick shake abruptly and asks client to open eyes, and checks for nystagmus.
5. If nystagmus occurs, the PT times how long the vertigo lasts before it subsides.
6. If BPPV is suspected, based on the direction and duration of the nystagmus, the therapist can move on to the treatment.

Please note that if you do have BPPV, these tests are not comfortable because they elicit dizziness. However, your physical therapist should put you in position where you’re not in any pain during this procedure.

What Nystagmus Can Tell a PT

Before talking about treatment, it’s important to understand nystagmus and how the direction and duration allow for the therapist to know which type of BPPV you’re experiencing. Click HERE to see a video of nystagmus.

Nystagmus is a rapid oscillation of the eyeball. When a PT looks at the eyes as nystagmus is occuring, it looks like the eyeballs are bouncing back and forth.

When someone has BPPV, the nystagmus is not just in a linear direction, but also has a slight rotation, called a torsion. The direction of the torsion (right or left) usually indicates which ear is affected.⁵

The direction they bounce indicates what canal the otoconia is in.

If the eyes bounce upwards, that indicates posterior canal BPPV.

Horizontal canal BPPV occurs when the eyes bounce down towards the ground (called “geotropic”) or up towards the client’s nose (called “ageotropic”),

If the eyes bounce downward, that indicates anterior canal BPPV.⁵

How Long Does the Nystagmus Last?

As mentioned above, the PT times how long the nystagmus lasts during the screening tests.

This is important because it indicates whether the patient has canalithiasis or cupulolithiasis.

When doing either the Dix-Hallpike or the Head Shake Test, the therapist is essentially moving the crystal within the canal.

The movement of the crystal is what causes dizziness and nystagmus to occur, which is why if you have experienced BPPV, you likely stopped moving your head in certain directions to avoid a dizzy spell.

When the crystal moves, the endolymph is dragging the cupula in a certain direction more than it’s used to, messing with the signal from cupula to brain.

When the crystal reaches its lowest point, the endolymph stops dragging the cupula and it can return to a neutral position, and nystagmus stops.⁴

This typically takes 30 seconds or less.

If nystagmus lasts longer, like 2 minutes, it could indicate cupulolithasis, as the weight of the otoconia on the cupula may be preventing it from returning to its neutral position.

How is BPPV Treated?

This depends on which type you have. Below, the most common techniques for the more common types of vertigo will be addressed.

Each treatment is designed to move the head in the correct way in order to move the crystal out of the semicircular canal and back into the utricle.

BPPV Treatment for Posterior and Anterior Canal Canalithiasis

The good news is that once a PT identifies posterior canal canalithiasis with the Dix-Hallpike maneuver, they can move straight into treatment, which is called the Epley maneuver.

Epley Maneuver:

1. Client is in Dix-Hallpike position, with head turned toward affected ear, head hanging off of treatment table.
2. After nystagmus subsides, PT moves client’s head to the opposite side and looks for nystagmus.
3. If nystagmus occurs, PT waits for nystagmus to subside.
4. If no nystagmus occurs, PT waits 30 seconds (or amount of time it took for nystagmus to stop in initial position).
5. PT then asks client to roll onto their side, towards non-affected ear and PT turns client’s head down towards the floor.
6. This position is held for 30 seconds (or amount of time it took for nystagmus to stop in initial position).
7. PT then asks client to sit up while PT holds client’s head in position.
8. Once in seated position, client will wait 15 minutes, avoiding excessive/sudden head movements.
9. Dix-Hallpike is usually repeated to ensure successful Epley maneuver.

Following this treatment, your PT will likely have you try to keep from excessive head turning for the next 24 hours- no going to the dentist or hairdresser, or doing activities that require excessively tilting head backwards.

Also, sleeping in a reclined position, rather than flat for at least one night, and not sleeping on your affected side for a week.⁶

Treatment for Horizontal Canal Canalithiasis

When horizontal canal BPPV is detected, a technique called a barbecue roll is performed.

Barbecue Roll⁷:

1. Client sits on treatment table/bed with legs in front of them.
2. Client slowly lowers to lying on their back.
3. Client rolls onto affected side, holds position for 30 seconds.
4. Keeping the head in contact with the pillow, client rolls to their back, holds position for 30 seconds.
5. Keeping the head in contact with the pillow, client rolls to their opposite side, holds position for 30 seconds.
6. Client then tucks their chin slightly and rolls on to their forearms and knees, keeping head down, holds position for 30 seconds.
7. Client then rolls to affected side, holds position for 30 seconds.
8. Client then sits up, keeping head level, and waits 5 minutes before repeating this maneuver.
9. After performing a second time, client keeps head level for 15 minutes.

With the barbecue roll, the maneuver may have to be performed over the course of multiple days. This maneuver is performed until dizziness subsides.

Generally, while a client is undergoing this treatment, the PT will ask for them to sleep in a semi-reclined position, rather than flat, and avoid excessive head movements.

Treatment for Cupulolithiasis

The biggest difference with treatment for cupulolithiasis is that the maneuver is done at a higher speed in order to essentially detach the otoconia from the cupula.

To do this, a Semont Maneuver is performed.

Semont Maneuver⁸:

1. Client sits up with legs off the edge of the treatment table.
2. The PT turns the client’s head away from the affected ear.
3. The PT quickly lowers the client onto their affected side, so the client is looking up towards the ceiling.
4. Nystagmus and dizziness may occur. PT holds client in this position for 30 seconds, or until nystagmus subsides.
5. Then, while holding client’s head in the same position, the PT moves the patient to their opposite side, so the client is looking down at the floor.
6. Nystagmus and dizziness may occur. PT holds client in this position for 30 seconds, or until nystagmus subsides.
7. Once nystagmus subsides, the PT helps sit the patient up.

Usually, dizziness subsides within a day or two, but it’s not uncommon to still feel dizzy immediately following the treatment. It’s important to wait 15 minutes before leaving the therapy clinic to ensure dizziness is subsided for at least the time being.

Maintain precautions of sleeping in reclined position, avoiding excessive head movements for the next 24-48 hours.

Is It True that BPPV Treatment Can Make the Dizziness Worse?

This is an understandable question, considering how horrible BPPV can feel.

It’s not that the treatment makes the BPPV worse, however, when attempting to move the crystal back into the utricle, it is possible that it will move to another canal instead.

If this occurs, the dizziness won’t resolve as expected.

However, doing another Dix-Hallpike will allow for the therapist to reassess the nystagmus and complete the proper treatment for the new position of the crystal.

So it’s not that treatment makes it worse, but for some people, part of the process of recovery involves multiple treatment sessions.

What Can You Expect During and After BPPV Treatment?

You will definitely feel dizzy during the treatment for BPPV. Unfortunately, creating the dizziness is the only way we can address it.

You may feel like you are going to vomit, or you may vomit. That’s okay, it happens. Just let your therapist know if you feel like you’re going to throw up.

You may still feel dizziness following the treatment session, but eventually it should resolve.

You may need more than one treatment before dizziness resolves completely.

Key Takeaways

1. Older adults are at higher risk for BPPV.
2. Talk to your physical therapist or healthcare provider about any symptoms of dizziness/lightheadedness you’ve experienced.
3. It’s important to get screened for BPPV to rule out more serious causes of dizziness.
4. It’s also important to get screened because BPPV treatment is available.
5. BPPV treatment is not necessarily instant, and may require multiple treatment sessions.
6. Ask your PT what precautions you should follow after having treatment for BPPV.

Have the Strength to Live Life to the Fullest!

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Sources:

1. https://www.nasa.gov/audience/forstudents/9-12/features/F_Human_Vestibular_System_in_Space.html
2. https://www.britannica.com/science/vestibular-system
3. https://my.clevelandclinic.org/health/diseases/11858-benign-paroxysmal-positional-vertigo-bppv
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC202288/
5. https://www.apta.org/patient-care/evidence-based-practice-resources/test-measures/dix-hallpike-test
6. http://www.otolaryngology-assoc.com/for_patients/vertigo_bppv_post_treatment_instructions.aspx
7. https://www.google.com/search?q=barbecue+roll&oq=barbecue+roll&aqs=chrome..69i57j0i512l6j46i175i199i512j0i512l2.2785j0j4&sourceid=chrome&ie=UTF-8#kpvalbx=_juqCYe20FNTZ9AOS_57IDQ17
8. https://www.healthline.com/health/semont-maneuver#the-semont-maneuver
9. https://pressbooks.umn.edu/sensationandperception/chapter/vestibular-transduction-draft/
10. https://commons.wikimedia.org/wiki/File:Vertigo.png
11. https://sml.snl.no/Epleys_man%C3%B8ver
12. Photos created on Canva.com and from Google images Creative and Common Licenses