Benign Positional Paroxysmal Vertigo (BPPV): Difference between revisions

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'''Original Editor '''- [[User:Lee Marshall|Lee Marshall]], [[User:Lauren Russell|Lauren Russell]], [[User:Brían Lillis|Brían Lillis]], [[User:Anna Thommasen|Anna Thommasen]] as part of the [[Current and Emerging Roles in Physiotherapy Practice|QMU Current and Emerging Roles in Physiotherapy Practice]] Project
'''Original Editors '''- [[User:Steve Blakely|Steve Blakely]]


'''Lead Editors''' - Your name will be added here if you are a lead editor on this page.&nbsp; 
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
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= &nbsp;Package Aims&nbsp;  =


The aim of this continuing professional development (CPD) package is to educate physiotherapists and increase awareness about Benign Paroxysmal Positional Vertigo (BPPV) in an aging population. It introduces some of the current issues surrounding management of BPPV and aims to help reduce falls and unplanned hospital admissions by encouraging early diagnosis and treatment of this condition.  
== Definition/Description ==
[[File:Vertigo.jpeg|right|frameless]]
Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of [[vertigo]], which is a symptom of the condition<ref name="Shim">Shim, D. B., Song, C. E., Jung, E. J., Ko, K. M., Park, J. W., &amp; Song, M. H. (2014). Benign Paroxysmal Positional Vertigo with Simultaneous Involvement of Multiple Semicircular Canals.Korean Journal of Audiology,18(3), 126. doi:10.7874/kja.2014.18.3.126</ref>. Though not fully understood, BPPV is thought to arise due to the displacement of otoconia (small crystals of calcium carbonate) from the maculae<ref name="Shim" /> of the inner ear into the fluid-filled semicircular canals. These semicircular canals are sensitive to gravity and changes in head position can be a trigger for BPPV<ref name="Ogun">Ogun OA, Janky KL, Cohn ES, Büki B, Lundberg YW. Gender-Based Comorbidity in Benign Paroxysmal Positional Vertigo. PLoS ONE. 2014;9(9). doi:10.1371/journal.pone.0105546.</ref>. The posterior canal is the most commonly affected site, but the superior and horizontal canals can be affected as well<ref name="Hain">Timothy C. Hain, MD, BENIGN PAROXYSMAL POSITIONAL VERTIGO, site: http://www.dizziness-and-balance.com/disorders/bppv/bppv.html , Page last modified: February 3, 2013</ref>. It should be noted that the superior canal is sometimes also referred to as the anterior canal and the horizontal canal is sometimes referred to as lateral canal. <br>


Not all aspects of BPPV are covered in-depth, but you are encouraged to use this package and its links as a guide to further your understanding of the condition and to guide future learning. A set of learning outcomes has been devised to help facilitate this process. At the end of this CPD package you should be able to:  
The peripheral vestibular labyrinth contains sensory receptors in the form of ciliated hairs in the three semicircular canals and in the ear’s otolithic organs. They respond to movement and relay signals via the eighth cranial nerve. Visual perception such as gravity, position, and movements also receive signals from somatosensory receptors in the peripheral vestibules. With the displacement of the otoconia into the semicircular canals, these delicate feedback loops relay conflicting signals that can result in any symptom related to BPPV<ref name="Sandhaus">Sonia Sandhaus, Stop the spinning: Diagnosing and managing vertigo. Nurse Practitioner. 2002 Aug 1;27(8): 11-23.</ref>.<br>


<br>• Describe BPPV and recognize the signs, symptoms, and pathophysiology related to this condition.<br>• Utilize an evidence-informed approach to diagnose and treat BPPV.<br>• Critique current management of BPPV and demonstrate how physiotherapists might contribute to diagnosis and treatment. <br>• Demonstrate the value of early diagnosis and treatment of BPPV in falls prevention and unplanned hospital admissions.<br>• Identify further learning needs associated with BPPV for practice.<br>• Critically reflect on your current and emerging role in diagnosis and treatment of BPPV.<br>  
BPPV can be classified as cupulolithiasis&nbsp;and canalithiasis. Cupulolithiasis is when the otoconia are adhered to the cupula, whilst canalithiasis is when the otoconia are free floating in the canal. Additionally, the type of nystagmus that a patient may display can be classified as geotropic or apogeotropic. Geotropic describes the nystagmus as a horizontal beat towards the ground. Apogeotropic describes the nystagmus as a horizontal beat towards the ceiling<ref name="Maia">Maia FZE. New treatment strategy for apogeotropic horizontal canal benign paroxysmal positional vertigo. Audiology Research. 2016;6(2). doi:10.4081/audiores.2016.163.</ref>. <br>


= Introduction  =
<br>


[[Image:Vertigo1.JPG|frame|center|A man suffering from vertigo]] &nbsp;
{{#ev:youtube|1AfvNsaQnTE|}}<ref> UPMC. What Is Benign Paroxysmal Positional Vertigo?
. Available from: https://www.youtube.com/watch?v=1AfvNsaQnTE [last accessed 26/8/2022]</ref>


<br>  
== Clinically Relevant Anatomy  ==
[[Image:Innerlabyrinth2.jpg|frame|right|100px|Interior View of Labyrinth]]'''Benign paroxysmal positional vertigo''' ('''BPPV''') is a specific type of vertigo that is brought on by a change in position of the head with respect to gravity. This disorder is caused by problems in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in the position of the head.<ref name="Bhattacharyya">Neil Bhattacharyya, Reginald F. Baugh, Laura Orvidas, David Barrs, Leo J. Bronston, Stephen Cass, Ara A. Chalian, Alan L. Desmond, Jerry M. Earll, Terry D. Fife, Drew C. Fuller, MPH, James O. Judge, Nancy R. Mann, Richard M. Rosenfeld, Linda T. Schuring, Robert W. P. Steiner, Susan L. Whitney, and Jenissa Haidari. [http://www.entnet.org/Practice/upload/BPPV-Els.pdf Clinical practice guideline: Benign paroxysmal positional vertigo]. Otolaryngology–Head and Neck Surgery, 2008, 139, S47-S81</ref>


== Defining BPPV ==
The vestibular system monitors the motion and position of the head in space by detecting angular and linear acceleration. The 3 semicircular canals in the inner ear detect angular acceleration and are positioned at near right angles to each other. Each canal is filled with endolymph and has a swelling at the base termed the ampulla. The ampulla contains the cupula, a gelatinous mass with the same density as endolymph, which in turn is attached to polarized hair cells. Movement of the cupula by endolymph can cause either a stimulatory or an inhibitory response, depending on the direction of motion and the particular semicircular canal<ref name="Lorne et al">Lorne S. Parnes, Sumit K. Agrawal and Jason Atlas. [http://www.cmaj.ca/cgi/content/full/169/7/681 Diagnosis and management of benign paroxysmal positional vertigo (BPPV)]. CMAJ. September 30, 2003; 169 (7)</ref>. There is a vestibular apparatus within each ear so under normal circumstances, the signals being sent from each vestibular system to the brain should match, confirming that the head is indeed rotating to the right, for example.


BPPV is a peripheral vestibular disorder characterized by short episodes of mild to intense dizziness and influenced by specific changes in head position. BPPV is the most common cause of vertigo accounting for nearly one-half of patients with peripheral vestibular dysfunction. It is often self-limiting, but in some cases may become chronic and greatly affect an individual’s quality of life.<ref name="Parnes">Parnes L, Agrawal S, Atlas J. Diagnosis and Management of Benign Paroxysmal Positional Vertigo (BPPV) 2003; 169(7): 681-693.</ref>
Within the labyrinth of the inner ear lie collections of calcium crystals known as otoconia. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position)<ref name="Lorne et al" />. When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris (colloquially ear rocks or crystals) within the affected semicircular canal causes abnormal (pathological) fluid endolymph displacement in the affected ear. This fluid displacement will send a signal to the brain indicating that rotational movement is occuring. However, the vestibular apparatus in the unaffected ear will not be transmitting the same signal because there are no loose otoconia triggering the hair cells abnormally. This resultant mismatch in signals coming from the right and left vestibular systems lead to the sensation of vertigo. This more common condition is known as canalithiasis. Vertigo associated with this condition will be of short duration, even if the person with the condition stays in the provocative position, because the endolymph and otoconia will quickly come to a rest so the hair cells will no longer be displaced and triggering the signal to the brain.  


&nbsp;&nbsp;
In rare cases, the crystals themselves can adhere to a semicircular canal cupula rendering it heavier than the surrounding endolymph. Upon reorientation of the head relative to gravity, the cupula is weighted down by the dense particles thereby inducing an immediate and maintained excitation of semicircular canal afferent nerves. This condition is termed cupulolithiasis. Vertigo associated with this condition will not resolve until the head is moved out of the provocative position because even when the endolymph comes to a rest, the adhered otoconia will continue to displace the hair cells and trigger the signal of movement to the brain.


== Related Anatomy of the Ear  ==
It can be triggered by any action which stimulates the posterior semi-circular canal which may be:
*Tilting the head
*Rolling over in bed
*Looking up or under
*Sudden head motion
BPPV may be made worse by any number of modifiers which may vary between individuals:
*Changes in barometric pressure - patients often feel symptoms approximately two days before rain or snow <ref>Korpon JR, Sabo RT, Coelho DH. Barometric pressure and the incidence of benign paroxysmal positional vertigo. American Journal of Otolaryngology. 2019 Sep 1;40(5):641-4. [https://pubmed.ncbi.nlm.nih.gov/31147143/#:~:text=Results%3A%20The%20incidence%20of%20BPPV,diagnoses%20(p%20%3D%200.0008).]</ref>
*Lack of sleep (required amount of sleep may vary widely)
*Stress


[[Image:BPPV otoconia-web.jpg|frame|right|Figure 1. Inner Ear Anatomy]]<br>The inner ear is quite complex and includes both the organs for hearing (the cochlea) and balance (vestibular) (see Figure 1). The vestibular section of the ear consists of the saccule, utricle and three semicircular canals (anterior, posterior and horizontal). Each of these canals plays an essential role in maintaining balance.<ref name="Fife">Fife TD. Benign paroxysmal positional vertigo. Seminars in neurology. 2009;29(5):500-508.</ref>The semicircular canals are responsible for detecting rotational movement of the head. They are situated at right angles to one another and contain fluid called endolymph. Inertial changes with rotation of the head cause this endolymphatic fluid to shift. The fluid shift lags behind movement of the head and as a result pressure is exerted on the cupula, the motion sensory receptor at the base of the canal. Information regarding movement is then transduced and sent to the brain for interpretation.<ref name="Fife" />
== Aetiology/Causes  ==


The saccule and utricle play a role in detecting linear acceleration along with gravity. The macula of the utricle is considered the structure at fault for BPPV. It contains otoconia (calcium carbonate particles) which are surrounded by a gelatinous matrix and stereociliary hairs (see Figure 2). These calcium particles behave similarly to endolymph, reacting to changes in gravity and acceleration.<ref name="Fife" />&nbsp;[[Image:Macula 2.PNG|frame|right|Figure 2. Macula of Inner Ear]]
The most common cause of BPPV is idiopathic. However, the vestibular system of the inner ear can also undergo degenerative changes as one ages which can attribute to a potential cause of BPPV. Under age 50, head injury is a common cause. Vestibular viruses and Meniere’s disease also play a role. BPPV can also be a result of surgery due to prolonged supine positioning and possible trauma to the inner ear<ref name="AHRF">American Hearing Research Foundation: Benign Paroxysmal Positional Vertigo (BPPV). http://www.american-hearing.org/disorders/benign-paroxysmal-positional-vertigobppv/</ref>.<br>


<br><br>&nbsp;  
Risk factors include<ref name="Ogun" /><ref name="Chen">Chen, Z., Chang, C., Hu, L., Tu, M., Lu, T., Chen, P., &amp; Shen, C. (2016). Increased risk of benign paroxysmal positional vertigo in patients with anxiety disorders: a nationwide population-based retrospective cohort study.BMC Psychiatry,16(1). doi:10.1186/s12888-016-0950-2</ref><ref name="Gaur">Gaur S, Awasthi SK, Bhadouriya SKS, Saxena R, Pathak VK, Bisht M. Efficacy of Epley’s Maneuver in Treating BPPV Patients: A Prospective Observational Study. International Journal of Otolaryngology. 2015;2015:1-5. doi:10.1155/2015/487160.</ref>:
* Female gender
* falls
* Hypertension (HTN)
* Hyperlipidemia 
* Cerebrovascular disease
* [[Menopause]] 
* Allergies 
* [[Migraine Headache|Migraine]]
* Chronic Obstructive Pulmonary Disease ([[COPD (Chronic Obstructive Pulmonary Disease)|COPD]])
* Surgical procedure such as a cochlear implant 
* Infection


<br>
== Prevalence&nbsp;  ==


<br>  
*Dizziness is the complaint in 5.6 million clinical visits in the United States per year, and between 17 and 42 percent of these patients are diagnosed with BPPV<ref name="Bhatt">Bhattacharyya N, Baugh R, Orvidas L, Barrs D, Bronston L, Haidari J, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology--Head And Neck Surgery: Official Journal Of American Academy Of Otolaryngology-Head And Neck Surgery, 2008, Nov; 139(5 Suppl 4): S47-S81</ref>.
*Female to male ratio is 3:1<ref name="Chen" />
*The recurrence rate for individuals at one year following initial bout of BPPV is 15% and at 5 years the recurrence rate is 37-50%<ref name="Horn">Hornibrook, J. (2011). Benign Paroxysmal Positional Vertigo (BPPV): History, Pathophysiology, Office Treatment and Future Directions.International Journal of Otolaryngology,2011, 1-13. doi:10.1155/2011/835671</ref>.
*Individuals with a clinical diagnosis of anxiety are 2.7 times more likely to develop BPPV<ref name="Chen" />.
*Unilateral posterior canal is the most commonly affected canal in BPPV with 90% of all BPPV diagnosis<ref name="Bal">Balatsouras DG, Koukoutsis G, Ganelis P, Korres GS, Kaberos A. Diagnosis of Single- or Multiple-Canal Benign Paroxysmal Positional Vertigo according to the Type of Nystagmus. International Journal of Otolaryngology. 2011;2011:1-13. doi:10.1155/2011/483965.</ref>.
*Unilateral horizontal canal affects 5-15% of all BPPV diagnosis. Within a horizontal canal diagnosis, 2/3 of the cases are geotropic while 1/3 of the cases are apogeotropic<ref name="Bal" />.
*Anterior canal affects 1-2% of all BPPV diagnoses, which is the least common<ref name="Bal" />.
*The lifetime prevalence is 2.4 percent<ref name="Bhatt" />.


<br>  
== Clinical Presentation  ==
The signs and symptoms of BPPV are often transient, with symptoms commonly lasting less than one minute (paroxysmal).<ref name="Musat">Musat J. The Clinical Characteristics and Treatment of Benign Paraoxysmal Positional Vertigo in the Elderly. Romanian Journal of Neurology 2010;9(4):189-192.</ref> Episodes of BPPV can resolve after a few weeks or months, but may reappear at a later time. Screening for BPPV in all people with falls risk, whether dizzy or not, is important to detect all cases of BPPV.<ref name=":0">Susan Hyland, Lyndon J. Hawke & Nicholas F. Taylor (24 Feb 2024):Benign paroxysmal positional vertigo without dizziness is common in people presenting to falls clinics,Disability and Rehabilitation DOI:10.1080/09638288.2024.2320271</ref>


<br>  
The possible reasons why people test positive for  Signs and symptoms may include:<ref name="Musat" />
*Vertigo: Spinning sensation (<u>not</u> lightheadedness or feeling off-balance.)
**Short duration (Paroxysmal): Lasts only seconds to minutes (usually less than 60 seconds)<ref name="Strupp">Strupp M, Dieterich M, Brandt T. The Treatment and Natural Course of Peripheral and Central Vertigo. Deutsches Ärzteblatt International . 110(29):505-516.</ref>
**Positional in onset: only induced by a change in position
**Nausea
*Visual disturbance: It may be difficult to read or see during an attack due to the associated nystagmus.
**Pre-Syncope (feeling faint) or Syncope (fainting)
**Vomiting is uncommon, but possible.
*Loss of balance Symptoms are considered:
** Mild: inconsistent positional vertigo
** Moderate: frequent positional vertigo attacks with disequilibrium between vertigo attacks
** Severe: vertigo with most head movements, which can appear as continuous vertigo<ref name="Horn" />. Individuals with BPPV can have symptoms that last days, weeks, months or years before it is resolved<ref name="Horn" />.
Research suggests there is a definite correlation between cognitive skills and balance in women patients affected with chronic peripheral vestibulopathy<ref>Coelho AR, Perobelli JL, Sonobe LS, Moraes R, de Carneiro Barros CG, de Abreu DC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6828563/#!po=47.2222 Severe Dizziness Related to Postural Instability, Changes in Gait and Cognitive Skills in Patients with Chronic Peripheral Vestibulopathy.] International Archives of Otorhinolaryngology. 2020 Jan;24(01):e38-45.</ref>.
*'''Signs'''
**Rotatory (torsional) nystagmus, where the top of the eye rotates towards the affected ear in a beating or twitching fashion
== Associated Co-morbidities  ==
There are conditions that appear to more prevalent in patients that experience BPPV, for example:<ref name="Ogun" /><ref name="Maia" />
* [[Meniere's Disease|Meniere's disease]]
* Vertebral basilar insufficiency
* [[Migraine Headache|Migraine]]
* [[Multiple Sclerosis (MS)|Multiple sclerosis]]
* Infection: sinus or ear
* Thyroid problems
* Reduced bone mineral density
* Sudden hearing loss


<br>
==Differential Diagnosis==
 
<div class="row">
<br>
  <div class="col-md-4">Otological disorders include:<ref name="Bhatt" /> <br>
 
* [[Meniere's Disease|Meniere's disease]]  
<br>
* Vestibular neuritis
 
* Labyrinthitis
For more in-depth&nbsp;information regarding&nbsp;ear anatomy please&nbsp;click the link: <u>'''http://emedicine.medscape.com/article/1948907-overview#aw2aab6b3'''</u>
* Superior canal dehiscence syndrome
 
* Post-traumatic vertigo </div>
<br>
  <div class="col-md-4">Other possible causes are:<ref name="Bhatt" /><br>
 
* Anxiety or panic disorders
== Pathophysiology of BPPV  ==
* Cervicogenic dizziness
 
* Medication side effects
BPPV occurs when the otoconia of the macula are dislodged and transferred into the lumen of one of the semicircular canals. This unintentional movement interferes with the endolymphatic system and stimulates the motion receptor (ampulla) of the affected canal, resulting in vertigo.<ref name="Fife" />  
* Postural hypotension</div>
 
  <div class="" col-md-4''>Neurological disorders include:<ref name="Bhatt" /><br>
Following this phenomenon, nystagmus ensues as a result of either canalithiasis or cupulolithiasis. Canalithiasis refers to freely moving otoconia settling within the posterior semicircular canal, causing the canal to be gravitationally sensitive. This is thought to result in posterior canal BPPV, the most common form of the condition. In about 5% of cases cupulolithiasis occurs, where the otoconia adhere to the cupula of the lateral semicircular canal causing it to be heavier than the surrounding endolymph. This is thought to result in lateral canal BPPV. The direction of nystagmus is different depending on location of the calcium carbonate crystals. Nystagmus pattern is provoked by ampullary nerve excitation in the affected canal, which is directly connected to extraocular muscles of the eye.<ref name="Fife" />  
* [[Migraine Headache|Migraine]]-associated dizziness
 
* Vertebrobasilar insufficiency
The exact reason for the calcium crystals separating from the macula is not well understood. The condition is believed to arise following viral infection or trauma, but in the majority of cases it occurs in the absence of any identifiable illness or upset. It is also believed to be linked to age-related changes in the protein and gelatinous matrix of the otolithic membrane.<ref name="Fife" /><br>  
* Demyelinating diseases</div>
 
</div>
Further information regarding the history and pathophysiology of BPPV can be found in this journal article: [http://www.hindawi.com/journals/ijol/2011/835671/ http://www.hindawi.com/journals/ijol/2011/835671/] &nbsp;
== Contraindications ==
 
Physical therapy is not appropriate for unstable vestibular disorders such as
<br>
* [[Meniere's Disease|Meniere's disease]]
 
* Uncontrolled [[Migraine Headache|migraine]]
== Epidemiology of BPPV  ==
* Perilymph Fistula (PLF)
 
* Unresolved Superior Semicircular Canal Dehiscence (SSCD)
BPPV is an idiopathic condition with approximately 50-70% of cases occurring without any known cause. It is most prevalent in people between the ages of 50 and 70 years old, though it can occur at any time.<ref name="Parnes" /> The prevalence of BPPV has been reported to range from 10.7 to 64 per 100,000<ref name="Hilton">Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Systematic Review 2004: CD003162.</ref> and is the cause of at least 50% of reported cases of dizziness in the elderly population.<ref name="Froehling">Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population based study in Olmsted County, Minnesota. Mayo Clinic Proceedings. 1991;66:596-601</ref>.
* Sudden loss of hearing
 
* Ringing in one or both ears
In individuals under the age of 50 years BPPV most commonly occurs following head trauma. It is believed that the otoconia become dislodged due to concussive forces on the vestibular system. BPPV is also associated with viruses of the ear, ototoxicity, and migraines.<ref name="Ishiyama">Ishiyama A, Jacobson KM, Baloh RW. Migraine and benign positional vertigo. Ann Otol Rhinol Laryngol 2000;109:377–380.</ref>&nbsp;A European study, estimating the prevalence and incidence of BPPV in the general adult population showed a lifetime prevalence of 2.4%.<ref name="Von">Von Brevern M, Radtke, A, Lezius F, Feldmann M, Ziese T, Lempert T, Neuhauser H. Epidemiology of benign paroxysmal positional vertigo: a population based study. Journal of Neurology, Neurosurgery &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Psychiatry. 2007;78:710-715.</ref> Furthermore, the study found females were more likely to be affected than males, with a lifetime prevalence of 3.2% versus 1.6%, respectively.<br>  
 
== Relevance to Physiotherapy  ==
 
It is estimated that 9% of elderly patients receiving comprehensive geriatric assessment for non-balance-related health issues, have unrecognized BPPV.<ref name="Oghalai" /> These individuals experience higher incidences of falls, impairments of daily living, and depression.<ref name="Oghalai" /> Furthermore, falls in the elderly can result in secondary injury and may lead to unplanned nursing home and hospital admissions. Persistent untreated or undiagnosed vertigo in the elderly can lead to increased caregiver burden and resultant societal costs. Physiotherapy methods of diagnosis and treatment are safe, simple to administer, cost-effective, and encouraged to help relieve this burden.
 
The high percentage of undiagnosed patients is testament to the lack of knowledge surrounding BPPV. We believe it is crucial to educate and inform health care workers, namely physiotherapists, regarding this condition in order to reduce the amount of undiagnosed cases. Through this, we aim to reduce the number of unplanned hospital admissions and falls amongst the elderly population.<br>
 
= The Signs &amp; Symptoms =
 
The signs and symptoms of BPPV are often transient, with symptoms commonly lasting less than one minute (paroxysmal).<ref name="Musat">Musat J. The Clinical Characteristics and Treatment of Benign Paraoxysmal Positional Vertigo in the Elderly. Romanian Journal of Neurology 2010;9(4):189-192.</ref> Episodes of BPPV can resolve after a few weeks or months, but may reappear at a later time. Signs and symptoms may include:<ref name="Musat" /><br>  
 
• Dizziness<br>• Vertigo (a sense that your surroundings are spinning or moving)<br>• Lightheadedness <br>• Loss of balance<br>• Blurred vision and nystagmus associated with vertigo<br>• Nausea<br>• Vomiting[[Image:Dizziness1.jpg|thumb|right|A cartoon representation of someone with BPPV]]  
 
<br>Activities that bring about the signs and symptoms of BPPV can vary from person to person, but are almost always brought on by a change in the position of the head. These positional changes may include:<br>
 
• Moving the head to one side
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - example: when turning in bed <br>• Tilting the head backwards to look up
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; – example: hanging up washing or taking something from the top shelf<br>• Bending over
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; – example: to tie shoe laces
 
<br>The typical features of a patient presenting with BPPV include:<br>• &gt; 40 years of age<br>• Vertigo and dizziness lasting one minute or less<br>• One or more of the signs/symptoms listed above<br>• Onset of symptoms during activities which involve a change in the position of the head<br>• Limitations or modification of movements, to avoid provoking symptoms<br>• History of falls resulting from symptomatic episodes
 
= Diagnosis  =
 
== Principles of Clinical Diagnosis  ==
 
BPPV can easily be diagnosed and treated through simple clinic-based procedures.<ref name="Balasouras">Balasouras DG, Koukoutsis G, Ganelis P, Korres GS, Kaberos A. Diagnosis of single- or multiple-canal benign paroxysmal positional vertigo according the type of nystagmus. International Jounral of Otalaryngology. 2011; 1-13.</ref> In the past, a wide variety of different tests and procedures have been explored for diagnosis of BPPV, but many of these techniques have been discredited in recent years. Currently the primary method of diagnosis involves in-depth subjective screening, followed by physical investigations and diagnostic manoeuvres to confirm BPPV. These methods of diagnosis have been shown to be clinically appropriate, simple to perform, and cost effective.<ref name="Bhattacharyya" /> Early diagnosis of BPPV is important and may help improve quality of life for patients and reduce the risk of more serious injury. Techniques may be easily incorporated into routine physiotherapy assessment and should be considered for any patients presenting with symptoms of dizziness and vertigo.


== Diagnostic Procedures  ==
BPPV can easily be diagnosed and treated through simple clinic-based procedures.<ref name="Balasouras">Balasouras DG, Koukoutsis G, Ganelis P, Korres GS, Kaberos A. Diagnosis of single- or multiple-canal benign paroxysmal positional vertigo according the type of nystagmus. International Jounral of Otalaryngology. 2011; 1-13.</ref> In the past, a wide variety of different tests and procedures have been explored for diagnosis of BPPV, but many of these techniques have been discredited in recent years. Currently the primary method of diagnosis involves in-depth subjective screening, followed by physical investigations and diagnostic manoeuvres to confirm BPPV. These methods of diagnosis have been shown to be clinically appropriate, simple to perform, and cost effective.<ref name="Bhattacharyya" /> Early diagnosis of BPPV is important and may help improve quality of life for patients and reduce the risk of more serious injury. Techniques may be easily incorporated into routine physiotherapy assessment and should be considered for any patients presenting with symptoms of dizziness and vertigo. The condition is diagnosed from patient history (feeling of vertigo with sudden changes in positions) and by performing a positional test. Different positional test exist. The exact positional test used to confirm the presence of BPPV will depend on which semicircular canal is involved.
== Subjective Assessment  ==
== Subjective Assessment  ==


The subjective assessment is the first step in clinically diagnosing BPPV.&nbsp; Any complaints of dizziness necessitate the taking of a detailed patient history and further investigation of the symptoms.<ref name="Strupp">Strupp M and Brandt T. Diagnosis and treatment of vertigo and dizziness. Dtsch Arztebl Int. 2008; 105(10): 173-180.</ref> Patient history alone is insufficient to accurately diagnose BPPV, but patient description of vertigo can give a very good indication of the cause.<ref name="Bhattacharyya" /> Clinicians should look out for patients describing sudden severe attacks of vertigo or dizziness, precipitated by head position and movement.<ref name="Parnes" /> The most common movements thought to provoke symptoms are rolling over in bed, extension of the neck to look up, and bending forward.<ref name="Parnes" /> Patients typically describe their vertigo as a rotational or spinning sensation provoked by these movements.<ref name="Bhattacharyya" />  
The subjective assessment is the first step in clinically diagnosing BPPV.&nbsp; Any complaints of dizziness necessitate the taking of a detailed patient history and further investigation of the symptoms.<ref name="Strupp1">Strupp M and Brandt T. Diagnosis and treatment of vertigo and dizziness. Dtsch Arztebl Int. 2008; 105(10): 173-180.</ref> Patient history alone is insufficient to accurately diagnose BPPV, but patient description of vertigo can give a very good indication of the cause.<ref name="Bhattacharyya" />  However, people with risk of falls without symptoms of dizziness should be assessed. <ref name=":0" />Clinicians should look out for patients describing sudden severe attacks of vertigo or dizziness, precipitated by head position and movement.<ref name="Parnes">Parnes L, Agrawal S, Atlas J. Diagnosis and Management of Benign Paroxysmal Positional Vertigo (BPPV) 2003; 169(7): 681-693.</ref> The most common movements thought to provoke symptoms are rolling over in bed, extension of the neck to look up, and bending forward.<ref name="Parnes" /> Patients typically describe their vertigo as a rotational or spinning sensation provoked by these movements.<ref name="Bhattacharyya" />  


Different studies have aimed to identify and validate useful questions when suspecting a diagnosis of BPPV. There are however no current guidelines for appropriate BPPV screening questions. Some important aspects of the condition have been identified which should be explored to rule out other causes. Clinicians should be asking patients questions regarding:  
Different studies have aimed to identify and validate useful questions when suspecting a diagnosis of BPPV. There are however no current guidelines for appropriate BPPV screening questions. Some important aspects of the condition have been identified which should be explored to rule out other causes<ref name="Strupp" />. Clinicians should be asking patients questions regarding:  


1. Type of dizziness and vertigo<br>2. Duration of dizziness and vertigo<br>3. Precipitating and exacerbating factors <br>4. Accompanying symptoms  
1. Type of dizziness and vertigo<br>2. Duration of dizziness and vertigo<br>3. Precipitating and exacerbating factors <br>4. Accompanying symptoms  


These criteria can help rule out other conditions and support a diagnosis of BPPV.<ref name="Strupp" />&nbsp;Noda et al.<ref name="Noda">Noda K, Ikusaka M, Ohira Y, Takada T, Tsukamoto, T. Predictors for benign paroxysmal positional vertigo with positive Dix-Hallpike test. International Journal of General Medicine. 2011; 4: 809–814.</ref> found that the trigger and duration of vertigo were particularly important in diagnosing BPPV. They highly suggest asking patients questions to explore whether they experience onset of dizziness when turning over in bed and dizziness for less than 15 seconds.<ref name="Noda" /> Answering yes to either of these questions indicates a potential diagnosis of BPPV. In addition to this, practitioners should ensure that rotatory vertigo, or a spinning sensation, is being experienced and distinguish this from light-headedness, which is dizziness without the sensation of movement.<ref name="Strupp" />
== Physical Assessment ==
 
If details of the subjective assessment and patient history indicate BPPV, then further physical investigation is needed to confirm a diagnosis. Physical diagnosis maneuvers involve a series of movements which aim to provoke nystagmus and symptoms of vertigo. The two diagnostic maneuvers used clinically are the Dix-Hallpike maneuver and the Supine Roll Test. A positive result on either of these tests indicates a diagnosis of BPPV. They also help to distinguish the type of BPPV and identify the ear involved.
Once the subjective assessment is complete, the health care professional should have a good idea whether further investigation is needed. As mentioned, patient history and subjective examination is insufficient to accurately diagnose BPPV on its own, but should be sufficient to rule out other causes of dizziness and develop a working hypothesis to guide the physical examination.&nbsp; <br>
=== Dix Hall Pike ===
 
The most commonly used test is Dix-Hallpike which assesses involvement of the posterior canal (the most commonly affected semicircular canal).<ref name="Lorne et al4">Lorne S. Parnes, Sumit K. Agrawal and Jason Atlas. [http://www.cmaj.ca/cgi/content/full/169/7/681 Diagnosis and management of benign paroxysmal positional vertigo (BPPV)]. CMAJ. September 30, 2003; 169 (7)</ref> The test involves turning the head 45 degrees to the side being tested and then quickly moving from a seated to a supine position with the head declined 30 degrees below the trunk. The test must be performed quickly to ensure sufficient displacement of the endolymp and otoconia to provoke the expected symptoms. The test is considered positive for canalithiasis of the posterior canal if vertigo is provoked and nystagmus is observed, both of which should be of short-duration for canalithiasis. The direction of the observed nystagmus should be consistent with the canal being assessed.&nbsp;For the posterior canal, nystagmus should be up-beating and torsional in an ipsilateral direction (if testing the affected side. If the left side is affected but the test is performed with the head turned to the right, the nystagmus would be up-beating and torsional to the right).  
== Physical Assessment ==
 
If details of the subjective assessment and patient history indicate BPPV, then further physical investigation is needed to confirm a diagnosis. Physical diagnosis maneuvers involve a series of movements which aim to provoke nystagmus and symptoms of vertigo.&nbsp; The two diagnostic maneuvers used clinically are the Dix-Hallpike maneuver and the Supine Roll Test. A positive result on either of these tests indicates a diagnosis of BPPV. They also help to distinguish the type of BPPV and identify the ear involved.&nbsp;
 
=== Dix-Hallpike Maneuver  ===
 
Evidence-based guidelines state that clinicians should diagnose posterior canal BPPV when vertigo and associated nystagmus is provoked by the Dix-Hallpike maneuver. <ref name="Bhattacharyya">Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology-Head and Neck Surgery 2008;139(5):S47-S81.</ref>&nbsp;This test is considered the gold standard for diagnosis of posterior canal BPPV.<ref name="Bhattacharyya" /> As posterior canal BPPV is the most common type of BPPV, occurring in up to 90% of cases, this is the first maneuver which should be performed during the physical examination.<ref name="Balasouras" /> The clinician should look for provocation of nystagmus and make note of the direction and pattern of eye movements, as this will give an indication of the ear at fault. Nystagmus may fatigue and reduce with repetition of the maneuver, so looking out for this symptom is important to minimize the need for repeat testing.<ref name="Bhattacharyya" /> Continued communication with the patient is essential to help establish and monitor when uncomfortable symptoms of vertigo arise.
 
==== Performing the Dix-Hallpike Maneuver  ====
 
Prior to initiation of the maneuver clinicians should explain the basic features of the test and warn patients that it may provoke sudden onset of vertigo. After informed consent has been given, the patient is positioned in supine so that the head can hang, with support, off the posterior edge of the examination table by 20°.<ref name="Bhattacharyya" /> The examiner should be in a position so that they are able to take the patient through the maneuver safely and effectively without losing support of the head.&nbsp;Bhattacharyya et al.<ref name="Bhattacharyya" /> give a good description of the maneuver and break the procedure down into a series of five steps (see Figure 3):
 
Step 1) To begin the maneuver the patient should be seated on a table or plinth in an upright position, with the examiner to one side.&nbsp;&nbsp;[[Image:Dix-hallpike.jpg|thumb|right|Figure 3. Performing the Dix-Hallpike Maneuver]]
 
Step 2) The examiner rotates the patient’s head 45° to one side and positions their own body so that rotation may be maintained through the next portion of the maneuver. If the right side is to be tested then the head begins rotated 45° to the right. If the left side is being tested the head begins rotated 45° to the left.
 
Step 3) With the head fully supported and maintained at 45° of rotation, the examiner quickly moves the patient from the seated position to a supine position with the patient’s neck extended 20° off the edge of the examination table. The patient’s eyes should be visible and examined for nystagmus, making note of the latency, duration and direction of movement. The patient should also be questioned regarding symptoms of vertigo.
 
Step 4) After resolution of vertigo and nystagmus, the patient is slowly returned to the upright position. Patients may experience a reversal of the nystagmus when returning to this position and symptoms should be allowed to resolve before moving on.
 
Step 5) The entire maneuver should then be repeated with the head rotated to the opposite side.
 
<br>
 
<u></u>
 
<u></u>
 
<u>A video demonstration of the Dix-Hallpike Maneuver and associated nystagmus</u>
 
{{#ev:youtube|8NxjG80V7OU}}<ref>Dix Hallpike. [Video: Website]. http://www.youtube.com/watch?v=8NxjG80V7OU . 2011. (Accessed October 30 2012).</ref>
 
A positive Dix-Hallpike maneuver will elicit a typical pattern of nystagmus described as a mix of torsional and vertical movement, with the upper pole of the eye beating toward the downward facing affected ear.<ref name="Balasouras" /> If one ear is affected, nystagmus will be provoked when the affected ear is positioned downwards and not upwards. If both ears are affected nystagmus is elicited in both directions. A summary table of possible nystagmus characteristics has been provided.
 
==== Diagnostic Strength of Dix-Hallpike Maneuver  ====
 
As mentioned, the Dix-Hallipike maneuver is considered the gold standard test for the diagnosis of posterior canal BPPV and as such is one of the most common tests used for diagnosis.<ref name="Bhattacharyya" /> As the current gold standard, few tests have explored the sensitivity and specificity of this maneuver, but studies have reported sensitivity up to 82% and specificity of 71% amongst experienced clinicians.<ref name="Lopez">Lopez-Escamez J, Gamiz M, Fernandez-Perez A, Gomez-Fiñana M, Sanchez-Canet I. Impact of treatment on health-related quality of life in patients with posterior canal benign paroxysmal positional vertigo. Otology &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; neurotology. 2003; 24(4): 637-641.</ref>&nbsp;It is proposed to have a positive predictive value of 83% and a negative predictive value of 52%.<ref name="Hanley">Hanley K and O-Dowd T. Symptoms of vertigo in general practice a prospective study of diagnosis. British Journal of General practice. 2002; 52: 809-812.</ref>&nbsp;Due to the lower negative predictive value, a negative result cannot entirely rule out a diagnosis of posterior canal BPPV. If BPPV is still suspected, the test may need to be repeated on subsequent visits to confirm a negative or positive diagnosis.<ref name="Bhattacharyya" />
 
<br>
 
=== Supine Roll Test  ===
 
If the Dix-Hallpike maneuver is negative, the patient should be tested for lateral (also referred to as horizontal) canal BPPV using the supine roll test.&nbsp; Lateral canal BPPV is the second most common type of BPPV with incidences of 10% to 15%.<ref name="Bhattacharyya" /> The supine roll test is the preferred maneuver to diagnose lateral canal BPPV, though it is not as well-established as the Dix-Hallpike maneuver.<ref name="Balasouras" /> Again, the clinician should look for provocation of nystagmus and make note of the direction and pattern of eye movements.&nbsp; Prior to initiation of the maneuver, clinicians should explain the basic features of the test and warn patients that it may provoke sudden onset of vertigo. A positive test is indicated by the presence of vertigo and elicitation of nystagmus. The procedure may be broken down into some simple steps (see Figure 4):
 
Step 1) The patient is initially positioned in supine with the head in a neutral position over the edge of the table.
 
Step 2) With support from the clinician, the head is quickly rotated 90° to one side with the clinician observing the eyes for nystagmus.
 
Step 3) After any elicited nystagmus has resided, the head is returned to neutral and the eyes are once again observed for nystagmus.
 
<br>
 
[[Image:Supine roll test.jpg|frame|center|Figure 4. Supine Roll Test]]
 
A positive supine roll test will evoke two different patterns of nystagmus, which reflect the two different types of lateral canal BPPV. The two types of lateral canal BPPV are Geotropic and Apogeotropic.&nbsp; The pattern of nystagmus may also be described as geotropic or apogeotropic. Geotropic nystagmus refers to a nystagmus pattern where the upper half of the eye is directed towards the ground. Apogeotropic nystagmus refers to the opposite movement. The typical pattern of nystagmus seen for each type of BPPV is presented in the table below.<br>
 
=== Patterns of Nystagmus  ===
 
Table 1. was adapted from Balasouras et al.<ref name="Balasouras" /> and provides a basic summary of the different patterns of nystagmus which can be elicited by the two diagnostic maneuvers discussed. For additional information on the characteristic patterns of nystamus provoked in patients with BPPV, the reader is directed to Balasouras et al.<ref name="Balasouras" />, Parnes et al.<ref name="Parnes" />, and Bhattacharyya et al.<ref name="Bhattacharyya" />.
 
&nbsp;&nbsp;&nbsp; [[Image:Pattern of Nystagmus.JPG|frame|center|Table 1. Patterns of Nystagmus]]
 
=== Imaging and Additional Investigations  ===
 
Imaging and additional testing is generally not required or recommended for confirming diagnosis of BPPV, unless additional neurological symptoms exist or the patient has additional symptoms which warrant further exploration.<ref name="Balasouras" /><ref name="Bhattacharyya" /><ref name="Alvarenga">Alvarenga GA, Barbosa MA, Porto CC. Benign paroxysmal positional vertigo without nystagmus: diagnosis and treatment. Brazilian Journal of Otorhinolaryngol. 2002; 77(6): 799-804.</ref>&nbsp;Imaging is not deemed to be useful in regular diagnosis of BPPV as the pathology occurring within the semicircular canals of the ear is beyond the resolution of current neuroimaging techniques.<ref name="Bhattacharyya" />
 
<br>
 
= Treatment  =
 
== Treatment Techniques for BPPV  ==
 
Management of BPPV has changed drastically over the past 20 years. Traditionally, treatment included advice on avoiding movements that induced vertigo and patients were prescribed medications for symptomatic relief.<ref name="Parnes" /> Currently a shift has occurred towards treatment involving manual therapy and self-management techniques taught by qualified professionals. While spontaneous resolution of BPPV is possible, manual techniques are effective, easy to administer, and should be considered the first line of treatment.<ref name="Angeli" />
 
The correct treatment technique will depend on which side and semicircular canal has been affected.<ref name="Swartz">Swartz R, Longwell P. Treatment of Vertigo. American Academy of Family Physicians. 2005; 71: 1115-1122.</ref>&nbsp;Both the Modified Epley’s Maneuver and the Semont Liberatory Maneuver have been found to be beneficial in reducing symptoms of BPPV resulting from pathology of the posterior semicircular canal. Lateral canal positioning techniques have been shown to improve symptoms arising from pathology of the lateral semicircular canal.<ref name="Parnes" />
 
=== <br>Treatment Techniques for Posterior Canal BPPV  ===
 
==== Modified Epley's Maneuver&nbsp;  ====
 
In 1992, Epley<ref name="Epley92">Epley J. The Canalith Repositioning Procedure: For Treatment of Benign Paroxysmal Positional Vertigo. American Academy of Otolaryngology- Head and Neck Surgery Foundation. 1992; 107(3): 399-404.</ref> first described the Canalith Repositioning Procedure (CRP) and demonstrated that 100% of the patients’ symptoms were relieved with this technique. Originally, Epley’s maneuver included sedation and mechanical skull vibrations.<ref name="Parnes" /> A modified Epley’s&nbsp;maneuver, or Particle Repositioning Maneuver (PRM), has since been created that does not involve skull vibrations or sedation. It is show to be equally beneficial and easier to administer than the original technique.<ref name="Parnes" /> Epley’s maneuver is designed to utilize gravity to move debris through the posterior semicircular canal into the utricle, resulting in decreased symptoms of BPPV.<ref name="Epley95">Epley J. Positional Vertigo Related to Semicircular Canalithiasis. American Academy of Otolaryngology- Head and Neck Surgery Foundation. 1995; 112: 154-161.</ref> It has been found to be well tolerated by patients and has a high success rate.<ref name="Helminski">Helminski J, Zee D, Janssen I, Hain T. Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review. Physical Therapy. 2010; 90: 663-678.</ref> Epley’s maneuver involves the following steps (see Figure 5):
 
Step 1) Place the patient in a sitting position
 
Step 2) Rotate the patient’s head 45° towards the effected ear
 
of neck extension where the affected ear is pointed towards the ground[[Image:Epley.gif|thumb|right|Figure 5. The Epley's Maneuver]]
 
Step 3) Hold the position for 30 seconds
 
Step 4) Turn the head 90° so that the unaffected ear faces the ground, ensuring that 30° of neck extension is maintained
 
Step 5) Hold the position for 30 seconds
 
Step 6) Keeping the head and neck in this position relative to the body, the patient rolls onto their shoulder that the head is facing (resulting in the rotation of the head another 90o and the patient should be looking downwards at a 45° angle
 
Step 7) Hold the position for 30 seconds
 
Step 8) Bring the patient to an upright posture while maintaining the 45° rotation of the head
 
Step 9) Have the patient sit for 30 seconds.<ref name="Gans">Gans R, Harrington-Gans P. Treatment Efficacy of Benign aroxysmal ositional Vertigo (BPPV) with Canalith Repositioning Maneuver and Semont Liberatory Maneuver in 376 Patients. Vestibular Diagnosis and Rehabilitation Science and Clinical Application. 2002; 23(2): 129-142.</ref><br>
 
<br>
 
<u>A video demonstration of the Modified Epley’s Maneuver</u>
 
{{#ev:youtube|7ZgUx9G0uEs}}&nbsp;<ref name="Epley">How to do the Epley Maneuver. [Video: Website] http://www.youtube.com/watch?v=7ZgUx9G0uEs. 2010 (Accessed October 23 2012)</ref>
 
Following the maneuver, the patient should be advised:<br>• To keep their head upright- Don’t pitch their head up or down<br>• Not to lie supine for 48 hours<br>• Not to lie on the affected side for 1 week<br>• Avoid bending over for 1 week (if possible)<br>• They may feel a sensation of light-headedness and may be slightly off balance for a few days following the treatment.<ref name="Kenny">Kenny T. Benign Paroxysmal Positional Vertigo. http://www.patient.co.uk/health/Benign-Paroxysmal-Positional-Vertigo.htm (Accessed October 16 2012).</ref><br>Following treatment, the patient may be taught to perform this maneuver on their own as a complimentary therapy.<ref name="Furman">Furman J, Hain T. “Do try this at home” Self-treatment of BPPV. Neurology. 2004; 63: 8-9.</ref>&nbsp;This can be especially beneficial for patients who do not respond to a single treatment, or those with frequent recurrence.<ref name="Furman" /> Recurrence rates have been estimated at 50% within the first 4-5 years after initial treatment. An accurate history is important to determine if the patient is at high risk of reoccurrence.<ref name="Nunez">Nunez R, Cass S, Furman J. Short- and long-term outcomes of canalith repositioning for benign paroxysmal positional vertigo. American Academy of Otolaryngology- Head and Neck Surgery Foundation. 2000; 122: 647-652.</ref>
 
When self-administered, Epley’s maneuver has been found to be more effective than the self-administered Semont Liberatory maneuver.&nbsp; It has been shown to be most beneficial when performed as an adjunct treatment to Epley’s maneuver administered clinically by a health care practitioner.<ref name="Helminski" /><br>
 
==== Semont Liberatory Maneuver&nbsp;  ====
 
First described in 1988, the Semont liberatory maneuver aims to move particles through the posterior semicircular canal and into the utricle, much like Epley’s maneuver.<ref name="Parnes" /> The Semont liberatory maneuver may be summarized in the following steps (see Figure 6):
 
Step 1) Place the patient in a sitting position with the head turned away from the affected side[[Image:Semont maneuver.jpg|thumb|right|Figure 6. The Semont Liberatory Maneuver]]
 
Step 2) Quickly and passively bring the patient backwards to a position of side lying (on the affected side) with the head turned upward
 
Step 3) Hold the position for 5 minutes
 
Step 4) Quickly and passively bring the patient back to the sitting position and then to side lying on the opposite side with the head turned downward
 
Step 5) Hold this position for 5 minutes
 
Step 6) Bring the patient to an upright posture.
 
<br>
 
<u>A video demonstration of the Semont Liberatory Maneuver</u><br>
 
{{#ev:youtube|A72UjulJSzE}}&nbsp;<ref name="Semont">Libertory Semont Maneuver for Right BPPV. [Video: Website]. http://www.youtube.com/watch?v=A72UjulJSzE. 2011. (Accessed October 23 2012)</ref>  
 
While the Semont liberatory maneuver has been shown to be effective, the quality of the research is poorer than that for the Epley’s maneuver.<ref name="Helminski" /> For this reason, Epley’s maneuver should be the main technique used in the treatment of BPPV.&nbsp; The Semont liberatory maneuver may be attempted if symptoms persist after administration of Epley’s maneuver.
 
=== Treatment Techniques for Lateral Canal&nbsp;BPPV  ===
 
While less common, lateral BPPV can be caused by particles within the lateral semicircular canal. A correct diagnosis of lateral BPPV is important as a posterior canal repositioning maneuver will be ineffective for this type of BPPV.<ref name="Parnes" />
 
==== Prolonged Position Maneuver  ====
 
The prolonged position maneuver can be used for lateral BPPV and involves the patient lying on their side with the affected ear up for 12 hours. It has been shown that this maneuver is effective and resolves symptoms in 90% of patients after the first attempt.<ref name="Parnes" />&nbsp;It is worth noting that with this maneuver there is a risk that some patients will experience movement of particles into the posterior canal, resulting in posterior BPPV.<ref name="Parnes" />&nbsp;If movement into the posterior canal occurs, the Epley’s maneuver can be applied to resolve symptoms.
 
==== Barrel Roll  ====
 
Another option for treatment of lateral canal BPPV is termed the “barrel roll”. In this maneuver the patient is rolled 360°, beginning and ending in the supine position, while maintaining the lateral semicircular canal perpendicular to the ground.<ref name="Parnes" /> During this treatment technique, the patient is rolled away from the affected ear in 90° increments until a full roll is achieved.<ref name="Parnes" />
 
The evidence for both of these treatment techniques is of low quality and further research is needed. Based on the current evidence, the rate of effectiveness for these treatment techniques is approximately 75%.<ref name="Bhattacharyya" /><br>&nbsp;
 
=== Vestibular Rehabilitation Exercises  ===
 
Vestibular rehabilitation exercises are commonly included in the treatment of BPPV and are designed to train the brain to use alternative visual and proprioceptive cues to maintain balance and gait.<ref name="Swartz" /> It has been shown that these exercises improved nystagmus, postural control, movement-provoked dizziness, the ability to perform activities of daily living independently, and levels of distress.<ref name="Swartz" />&nbsp;While no single vestibular rehabilitation exercise has been shown to reduce the symptoms of BPPV, a program of therapies that can include self-administered repositioning maneuvers, gaze stabilization exercises, falls prevention training, and patient education may be beneficial in reducing the symptoms of BPPV and improve quality of life.<ref name="Bhattacharyya" />
 
The evidence supporting the efficacy of vestibular rehabilitation exercises in reducing symptoms of BPPV is lacking.<ref name="Bhattacharyya" /> Steenerson et al.<ref name="Steenerson">Steenerson R, Cronin G. Comparison of the canalith repositioning procedure and vestibular habituation training in forty patients with benign paroxysmal positional vertigo. American Academy of Otolaryngology- Head and Neck Surgery Foundation. 1996; 114: 61-64.</ref>, found that Epley’s maneuver administered by a health care practitioner was a better treatment technique than vestibular rehabilitation exercises. Vestibular exercises were, however deemed to be better than no treatment at all. No single form of vestibular rehabilitation exercise has been found to be superior and exercises appear to have a greater effect when performed together, rather than as single exercises alone.<ref name="Bhattacharyya" /> <br>
 
==== Cawthorne-Cooksey Exercises  ====
 
The Cawthorne-Cooksey exercises aim to relax the neck and shoulder muscles, train eyes to move independently of the head, and to practice balance and head movements that cause dizziness.<ref name="Brain">Brain and Spine Foundation. Vestibular Rehabilitation Exercises: A Fact Sheet for Patients and Carers. http://www.brainandspine.org.uk/information/publications/brain_and_spine_booklets/vestibular_rehabilitation_exercises/index.html (Accessed October 12 2012).</ref> The exercises consist of a series of eye, head, and body movements, in increasing difficulty, which aim to provoke symptoms.<ref name="Bhattacharyya" /> The goal of these exercises is to fatigue the vestibular response and force the central nervous system to compensate by habituation to the stimulus.<ref name="Bhattacharyya" />
 
<br>
 
<u>A video description of the Cawthorne-Cooksey Exercises</u>
 
{{#ev:youtube|NXyg9n3nFQk}}&nbsp;<ref name="Cawthorne">Vestibular Rehabilitation Exercises. [Video: Website]. http://www.youtube.com/watch?v=NXyg9n3nFQk. 2011. (Accessed October 30 2012).</ref>
 
<br><br>
 
==== Brandt-Daroff Exercises  ====
 
The Brandt-Daroff exercises are a series of particle repositioning exercises that can be performed without a qualified health professional present and are easily taught to the patient.<ref name="Brain" />&nbsp;While beneficial, these exercises are more time consuming than other forms of treatment. They are completed by the patient in bed, 3 sets a day for 2 weeks and aim to help reduce the chance of reoccurrence of BPPV and promote the loosening of canaliths.<ref name="Bhattacharyya" /> Radke et al.<ref name="Radke">Radke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology. 1999; 53: 1358-1360.</ref> found that when these exercises are performed as the only form of treatment, they were successful at relieving the symptoms of BPPV in only 25% of individuals after one week of administration. The Brandt-Daroff exercises have been found to be a beneficial adjunct treatment in the symptomatic relief of BPPV.<ref name="Bhattacharyya" />
 
<br>The Brandt-Daroff exercises may be summarized in the following steps (see Figure 7):[[Image:Brandt.JPG|thumb|right|Figure 7. The Brandt-Daroff Exercises]]
 
Step 1) Have the patient sit on the edge of the bed and turn their head 45° to one side
 
Step 2) Quickly have the patient lie down on the opposite side that their head is facing
 
Step 3) Have the patient hold this position for 30 seconds
 
Step 4) Return to the sitting position
 
Step 5) Repeat steps 1-4 while facing the opposite direction, alternating until 6 repetitions have been completed.<ref name="Brain" />
 
<u>A video demonstration of the Brandt-Daroff Exercises</u>
 
{{#ev:youtube|CTZfIv165sY}}&nbsp;<ref name="Brandt">Brandt-Daroff Exercises for BPPV Dr. Michael Teixido. [Video: Website]. http://www.youtube.com/watch?v=CTZfIv165sY. 2011. (Accessed October 30 2012).</ref><br><br>
 
<br>
 
=== Medication  ===
 
Previously, vestibular suppressants have been prescribed to treat BPPV. These medications are shown to have little effect; with any positive result occurring over a similar timescale to that of a control, suggesting spontaneous resolution of the vertigo.<ref name="Bhattacharyya">Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology-Head and Neck Surgery 2008;139(5):S47-S81.</ref>&nbsp; Due to the mechanical nature of BPPV and its association with very brief episodes of vertigo, BPPV management via drugs is essentially ineffective.<ref name="Fife" />
 
= Implications in Falls and Unplanned Hospital Admissions&nbsp;&nbsp;  =
 
[[Image:Elderly falls.jpg|border|center]]<br>
 
== Falls: What's the Problem?  ==
 
Dizziness is one of the most common symptoms described by elderly people and can be associated with balance disorders, reduced quality of life, functional decline and falls.<ref name="Lawson">Lawson J, Johnson I, Bamiou DE, Newton JL. Benign paroxysmal positional vertigo: clinical characteristics of dizzy patients referred to a Falls and Syncope Unit. QJM: Journal of International Medicine 2005; 98:357–364.</ref><ref name="Pollack">Pollack L. Awareness of benign paroxysmal positional vertigo in central Israel. BMC Neurology 2009; 9:17:9-17.</ref> The incidence of falls is a huge problem when considered alongside the shifting demographics in the UK.<ref name="Scottish Executive">Scottish Executive. All Our Futures: Planning for Scotland with an Aging Population 2007. www.scotland.gov.uk (accessed 28 October 2012).</ref> There are large financial implications for the NHS in relation to hospitalization following falls and the cost of treating resultant injuries. The UK population is ageing and therefore the cost of falls incurred by the NHS and other agencies is expected to escalate.<ref name="Scottish Executive" />
 
<br>Here are some facts and figures which relate to falls:[[Image:Broken leg.jpg|border|right]]<br>
 
*In 2007 there were over 1 million falls<ref name="Age Scotland">Age Scotland. At Home with Scotland’s Older People: Facts and Figures 2011-2012, 2011 http://www.ageuk.org.uk/documents/en-gb-sc/policy/2011%20at%20home%20with%20scotland's%20older%20people%20-%20%20web%20pdf%20hi-res.pdf?dtrk=true (accessed 20th October 2012)</ref>
*One in 3 people over 65 have a fall every year<ref name="Age Scotland" />
*Every 5 hours in the UK, an elderly person dies after a fall at home<ref name="Age Scotland" />[[Image:Broken wrist.jpg|border|right]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
*Based on current trends in the UK, hip fractures among older people resulting from a fall may rise to 120,000 per annum by 2015<ref name="Age Scotland" />
 
<br>To put these figures into context, in relation to falls, in the UK:<br>
 
*&nbsp; One hip fracture every 9 mins; each with an estimated cost of £12,000-18,000<ref name="NHS Scotland">NHS Scotland. Prevention of Falls in Older People 2007. www.scotland.gov.uk/Resource/Doc/924/0076048.ppt (accessed 20th October 2012)</ref>
*&nbsp;One wrist fracture every 10 mins; each with an estimated cost of £450<ref name="NHS Scotland" />
*&nbsp;500 people admitted to hospital every day<ref name="NHS Scotland" />
 
<br>Falling has been reported as the primary reason for an elderly patient to be admitted to accident and emergency.<ref name="Zur">Zur O, Berner YN, Carmeli E. Correlation between vestibular function and hip fracture following falls in the elderly: a case-controlled study. Physiotherapy 2006;92(4):208-213.</ref> In addition, falling is the main mechanism for minor injury in the elderly population.<ref name="Marchetti" />
 
Falling is not just a problem attributed to the UK; approximately 40% of the population over the age of 65 in the USA falls at least once a year, with 1 in 40 of them being admitted to hospital. Of those that are hospitalized, only around half will still be alive 12 months later.<ref name="Rubenstein">Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006;35(suppl 2):ii37-ii41.</ref>&nbsp; Findorff et al.<ref name="Findorff">Findorff MJ, Wyman JF, Nyman JA, Croghan CF. Measuring the direct healthcare costs of a fall injury event. Nurs Res 2007;56(4):283-287.</ref> stated that 20-30% of people who fall in the USA require medical support, the cost of which is estimated at $6-8 billion per year. For those over the age of 65, falls account for approximately 6% of medical expenditure for that age-group within the USA.<ref name="Rubenstein" /> Based on the causes and circumstances of falls, it has been estimated that 2/3 of deaths caused by falls are in fact preventable.
 
These facts and figures clearly highlight the huge economic impact of falls on the NHS and financial obligation which accompanies treatment of associated injuries. It is imperative that illnesses/disorders which can make individuals more likely to suffer falls as a result of impaired balance are treated effectively. This will help to prevent unplanned hospital admissions which are both costly for the NHS and to the patients’ quality of life.<br>
 
== Impact of BPPV on Falls and Admissions  ==
 
It has been well established that disorders within the vestibular system increases the risk of falling.<ref name="Oghalai">Oghalai JS, Manolidis S, Barth JL, Stewart MG, Jenkins HA. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngology-Head and Neck Surgery 2000;122(5):630-634.</ref> The presence of the vestibular dysfunction means that patients do not receive the correct information signals, making them unable to initiate the appropriate avoidance behaviour prior to impact, worsening the eventual outcome of the fall.<ref name="Kristinsdottir">Kristinsdóttir EK, Jarnlo GB, Magnusson M. Asymmetric vestibular function in the elderly might be a significant contributor to hip fractures. Scand J Rehabil Med 2000;32(2):56-60.</ref> BPPV has been found to account for approximately 20% of all dizziness and is the most common vestibular disorder; BPPV is therefore hugely implicated in falls.<ref name="Musat" />
 
BPPV and other vestibular disorders have been deemed the primary etiology in 13% of falls. In a study by Oghalai et al.<ref name="Oghalai" /> it was found that out of a random sample of an inner-city geriatric population, 9% were found to have previously undiagnosed BPPV. They also found that those with unrecognized BPPV were more likely to have reduced activities of daily living scores and to have sustained a fall in the past 3 months. Gananca et al.<ref name="Gananca">Gananca FF, Gazzola JM, Aratani MC, Perracini MR, Gananca MM. Circumstances and Consequences of Falls in Elderly People with Vestibular Disorder. Rev Bras Otorrinolaringol 2006;72(3):388-93.</ref> carried out a study to determine the circumstances and consequences of falls in elderly people and found that 43.8% of the participants had BPPV diagnosis. Out of the 64 participants, over half (53.1%) had reported recurrent falls, with over 80% reporting a tendency to fall. This highlights vestibular disorders, within which BPPV appears to be most prevalent, as a major precursor of falls in the elderly.<ref name="Gananca" />
 
Research has shown that elderly patients suffering from BPPV suffer more falls than those not suffering from BPPV, increasing the likelihood of unplanned hospital admissions for secondary injuries such as fractures.<ref name="Bhattacharyya" /> Based on a recent survey in the USA, people over the age of 40, who reported dizziness and vertigo, were 12 times more likely to have also reported a fall.<ref name="Agrawal">Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001-2004. Arch Intern Med 2009;169(10):938</ref> Marchetti et al.<ref name="Marchetti">Marchetti GF, Whitney SL, Redfern MS, Furman JM. Factors Associated With Balance Confidence in Older Adults With Health Conditions Affecting the Balance and Vestibular System. Arch Phys Med Rehabil 2011 11;92(11):1884-1891.</ref> found that patients who had suffered a hip fracture were also likely to suffer from a vestibular dysfunction.
 
Due to the increased prevalence of BPPV with age, patients suffering from this condition will often have medical comorbidities which need to be taken into consideration when diagnosing and treating BPPV. Patients with BPPV demonstrate higher rates of diabetes, stroke, hypertension and vision problems.<ref name="Gananca FF">Gananca FF, Gazzola JM, Gananca CF, Caovilla HH, Gananca MM, Cruz OLM.Elderly Falls Associated with Benign Paroxysmal PositionalfckLRVertigo. Braz J Otorhinolaryngol.fckLR2010;76(1):113-20.</ref> Patients with pre-existing conditions, especially stroke and peripheral neuropathy (as a result of diabetes), may already have existing balance, gait and proprioceptive problems. This predisposes these patients to a greater risk of falling during symptomatic periods and great care must be taken to minimize these risks and ensure effective treatment.<ref name="Gananca FF" /> Patients who have osteoporosis are at greater risk of fractures from falls and therefore should be identified and monitored very closely with falls risk assessments.<ref name="Age Scotland" /> When looked at from a different perspective, it would be useful to routinely screen patients who are identified as having a history of recurrent falls for BPPV. This would ensure BPPV is diagnosed in patients who are routinely falling as a result of the condition and allow them to get the appropriate treatment, aiming to prevent future falls and unplanned hospitals admissions.
 
Individuals with balance or vestibular disorders such as BPPV have a tendency to restrict their activity levels and social commitments, in an attempt to avoid the consequences of falling.<ref name="Marchetti" /> It has been found that those patients with a fear of falling also report psychological issues such as reduced confidence, anxiety, and depression.<ref name="Age Scotland" /> This evidence highlights the effect that BPPV can have in diminishing the quality of life for sufferers.<br>
 
== What Role Do Physiotherapists Have?  ==
 
Acquiring a good knowledge of the pathophysiology, diagnosis and treatment techniques involved in the management of BPPV allows for early diagnosis and effective intervention. It is necessary for us, as physiotherapists to recognize BPPV in the initial assessment; avoiding unnecessary clinical tests and hospital visits being required before BPPV is diagnosed.<ref name="Pollack" /> As physiotherapists are often the first point of contact for these patients, it is vital that we have the skills to recognize BPPV. Once a diagnosis has been made, treatment can begin, this ensures that the patient recovers as quickly as possible, and minimizes the impact of BPPV on their life. In reality, diagnosis of BPPV is relatively straightforward when patient’s history and correct diagnostic tests are performed in the physical assessment.<ref name="Angeli">Angeli SI, Hawley R, Gomez O. Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngology--Head and Neck Surgery 2003;128(5):719-725.</ref> The treatment of BPPV, as described in this learning package, is also simple to perform and is a cost and time effective method of management. The impact of falls and hospital admissions resulting from BPPV is costly both in terms of healthcare bills but also on patients’ physical health and quality of life. At present, BPPV is being undiagnosed too frequently, and is often only recognized upon admittance due to a secondary injury caused by a fall.<ref name="Gananca FF" /> By physiotherapists having the appropriate knowledge and developing their skills in the diagnostic and treatment techniques, BPPV can be managed more effectively. Appropriate intervention by physiotherapists and other healthcare professionals can help to reduce the falls associated with BPPV and as a result prevent unplanned hospital admissions.
 
Due to the high recurrence rate of BPPV, it is recommended that patients are educated as to how to self-manage the condition so that if it does present itself again, the patient is able to treat themselves accordingly. A longitudinal study suggested that BPPV has a recurrence rate of between 40-50% in a 5 year follow up following treatment which was initially successful, therefore patients should be taught how to self-manage their condition, and therefore minimize the likelihood of readmission.<ref name="Fife" />&nbsp; If a patient is not seen until after a fall, it is imperative to discover what led to the fall, possibly getting reports from other witnesses such as family members who may have a better recollection of the incident.<ref name="Rubenstein" /> We, as physiotherapists have a huge role in falls prevention and need to be able to make an informed judgment for referral to falls prevention teams, especially if the patient has recurring BPPV. Post fall assessments have resulted in significantly fewer falls through the detection of risk factors and previously undetected conditions, thus reducing hospital admissions.&nbsp;
 
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== What Now?&nbsp;  ==
 
An increased knowledge and awareness of BPPV will have a positive impact on the health of the elderly population and their quality of life. These changes are extremely relevant in the context of the UK’s shifting demographics and ever-aging population and as physiotherapists we have an important role to play. Now that you have a basic understanding of the anatomy, pathophysiology and current management of this condition, you are encouraged to reflect on you current role in BPPV management and consider how your own practice may be improved. You are encouraged to further your learning by completing the self-test questions in the next section of this package.&nbsp;
 
<br>
 
= Self-Test  =
 
The following set of self-test questions has been developed to test your knowledge on BPPV and to encourage self-reflection on current practice. Many of the answers can be found within this CPD package, but the reader is encouraged to use links provided to explore additional resources available on this subject.
 
1) Explain in your own words what Benign paroxysmal positional vertigo (BPPV) is?<br>__________________________________________________________________________________________________________________________________________________
 
2) Describe the pathophysiology of BPPV and name the two most likely causes.<br>______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
3) Describe the possible signs and symptoms of a patient presenting with BPPV.<br>_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
4) What are some typical movements/activities which may provoke symptoms of BPPV?<br>_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
5) Create a series of questions which may be useful to ask the patient when suspecting a diagnosis of BPPV.<br>_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
6) Utilizing the links provided in this package, determine any cautions and contraindications which may affect performance of the Dix-Hallpike Maneuver and Supine Roll Test.<br>_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
7)&nbsp; Briefly describe what you need to look for when performing the Dix-Hallpike maneuver and Supine Roll Test.<br>_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
8) Think about how you might describe the Dix-Hallpike maneuver and Supine Roll Test to the patient. What elements of these tests might be important for the patient to understand before administration?<br>______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
9) Using the links provided watch videos on the diagnostic and treatment techniques discussed in this package. If you are still unclear on the techniques ask a colleague or supervisor for advice and guidance. <br>____________________________________________________________________________________________________________________________________________________________________________
 
10) a. A patient is suffering from BPPV in the right posterior semicircular canal.&nbsp; Which of the two diagnostic tests would elicit a positive result? What characteristic symptoms would you expect to see upon completion of this test?<br>_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


b. What treatment approach would you take and how might you modify the Epley’s maneuver to be used for treatment of this patient?<br>______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
=== Horizontal Roll Test ===
This test is to assess the horizontal semicircular canal
# Patient is supine. Examiner flexes the cervical spine 20-30 degrees.
# Examiner quickly rotates the head to the right approximately 45 degrees. Hold for 30 seconds or until nystagmus and/or other symptoms have subsided
# Slowly return patient's head to midline.
# Next, quickly rotate patient's head to the left approximately 45 degrees.Hold for 30 seconds or until nystagmus and/or other symptoms have subsided.
# Slowly return patient's head to midline.
# Test is positive for nystagmus of other symptomatic complaints during the test. The patient may be positive on both sides. If this happens, the side that has more intense symptoms is considered the affected side.<be>


11) a. A patient presents with left lateral canal BPPV. What characteristic symptoms would you expect to see? How would you go about treating this patient?<br>______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
<div class="row">
  <div class="col-md-6"> {{#ev:youtube|R-uVlxWDu4k|300}} <div class="text-right"><ref>Ascension Via Christi. Dix Hallpike Maneuver. Available from: https://www.youtube.com/watch?v=R-uVlxWDu4k [last accessed 14/7/2022]</ref></div></div>
  <div class="col-md-6"> {{#ev:youtube|U3SGJfjwJaw|300}} <div class="text-right"><ref>Ascension Via Christi. Supine Roll Maneuver. Available from: https://www.youtube.com/watch?v=U3SGJfjwJaw [last accessed 14/7/2022]</ref></div></div>
</div>


b. What is the possible side effect of attempting a lateral canal repositioning technique? What can be done if this side effect occurs?<br>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
=== Head Pitch Test (“Bow and Lean” Test) ===
This test is used to assess unilateral horizontal canal BPPV<ref name="Bal" />
# Patient is seated
# Examiner first bends the patient’s head forward 30 degrees. Reassess nystagmus. Patient’s nystagmus should disappear because the horizontal canal is now in a true horizontal position.
# Examiner then bends the patient’s head forward to 60 degrees. Reassess nystagmus. A fast paced nystagmus may be present. If the nystagmus is being caused by the otoconia moving, the nystagmus will beat toward the affected ear. If the otoconia is attached to the cupula, the nystagmus will beat towards the unaffected ear.
# Examiner bends the patient’s head backwards 30 degrees. Reassess nystagmus. May see an increase in nystagmus due to the horizontal canal being vertical
The nystagmus associated with BPPV has several important characteristics which differentiate it from other types of nystagmus.
*Positional: the nystagmus occurs only in certain positions
*Latency of onsent: there is a 5-10 second delay prior to onset of nystagmus
*Nystagmus lasts for 5-30 seconds
*Visual fixation does not suppress nystagmus due to BPPV
*Both a rotatory and upbeat vertical components are present
*The nystagmus beats in a geotrophic (top of the eye towards the ground fashion
*Repeated Dix-Hallpike maneuvers cause the nystagmus to fatigue or disappear temporarily<u></u>


12) Take a moment to reflect on your own practice.&nbsp; How do you usually asses and treat patients who present with episodes of dizziness? Are there any things you would change, based on this information in this package?<br>______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If nystagmus and vertigo are sustained, cupulolithiasis or a potentially more central cause of vertigo should be considered. Patient history and other neurological tests can help to rule out a more serious central cause.


13) Make a list of questions you still have regarding BPPV. Utilizing the links provided to see if you can answer these questions.<br>______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
== Physiotherapy Management ==


14) Discuss with a colleague the implications of early BPPV diagnosis and treatment in falls prevention and unplanned hospital admissions. Are there any things you can do as practitioners to influences these?<br>______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<br>


<br>  
Research review implies that the posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment, and the choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient.<ref>Curr Treat Options Neurol. 2019 Dec 5;21(12):66. [https://www.ncbi.nlm.nih.gov/pubmed/31807976 doi: 10.1007/s11940-019-0606-x.]</ref>
Two treatments have been found effective for relieving symptoms of posterior canal BPPV:
# Canalith repositioning procedure (Epley maneuver)
#* Employs gravity to move calcium build-up that causes the condition
#* Can also be performed by trained otolaryngologists, neurologisists, chiropractors or audiologists
# Liberatory or Semont maneuver


For a printable PDF of the self-test questions please follow this link: [[Image:BPPV CPD Self-Test Questions.pdf|BPPV CPD Self-Test Questions]]  
<div class="row">
  <div class="col-md-6"> {{#ev:youtube|VtJB5Vx7Xqo|300}} <div class="text-right"><ref>AquacarePT. How to perform the epley maneuver at home for BPPV. Available from: https://www.youtube.com/watch?v=VtJB5Vx7Xqo [last accessed 26/8/2022]</ref></div></div>
  <div class="col-md-6"> {{#ev:youtube|A72UjulJSzE|300}} <div class="text-right"><ref> Michigan Medicine. Liberatory Semont Maneuver for Right BPPV. Available from: https://www.youtube.com/watch?v=A72UjulJSzE&t=2s [last accessed 26/8/2022]</ref></div></div>
</div>


= Links  =


<u>Defining BPPV and its Pathophysiology&nbsp;</u>  
=== Epley Maneuver ===
# Patient starts in long sitting, head rotated 45 degrees to affected side
# Patient rapidly reclined to supine position with neck slightly extended. Hold position for 30 seconds, or until nystagmus and dizziness subside
# Rotate head 90 degrees to opposite side. Hold position for 20 seconds, or until nystagmus and dizziness subside
# Patient rotated 90 degrees from supine to side-lying. Hold position for 20 seconds, or until nystagmus and dizziness subside
# Bring patient up into short-sitting  <br>May need to complete this maneuver 1 to 3 visits complete resolution of symptoms.


*http://www.hindawi.com/journals/ijol/2011/835671/
=== Semont Maneuver ===
*http://www.neuroanatomy.wisc.edu/selflearn/BPPV.htm
# Patient sits in short sitting, head rotated 45 degrees towards unaffected ear<ref name="Horn" />
# Examiner places one hand under the bottommost shoulder while the other hand supports the neck
# Patient rapidly moves into side-lying to the affected side (face should be oriented towards ceiling). Hold this position for 30 seconds
# Without any head movement, patient is to move to side-lying on opposite side of the body (face oriented towards bed). Hold this position for 30 seconds 


<u>Signs and Symptoms</u>


*http://synapse.koreamed.org/DOIx.php?id=10.3988/jcn.2010.6.2.51&amp;vmode=FULL<br>
<div class="row">
  <div class="col-md-6"> {{#ev:youtube|ufD_tcSx5dQ|300}} <div class="text-right"><ref>Ascension Via Christi. Barbeque Roll Lempert maneuver. Available from: https://www.youtube.com/watch?v=ufD_tcSx5dQ [last accessed 26/8/2022]</ref></div></div>
  <div class="col-md-6"> {{#ev:youtube|gTkZs0EcREY|300}} <div class="text-right"><ref>Gelreziekenhuizen. Gufoni manoeuvre. Available from: https://www.youtube.com/watch?v=gTkZs0EcREY [last accessed 26/8/2022]</ref></div></div>
</div>


<u>Diagnostic Videos</u>
=== Lempert Maneuver ===
Treatment for horizontal/lateral canal BPPV
# Patient lie supine on examination table, affected ear down
# Quickly turn the head 90 degrees towards unaffected side facing up
# Wait 15-20 seconds between each head turn
# Turn the head 90 degrees so affected ear is up
# Have patient tuck arms to chest, roll patient into prone
# Have patient turn on side as you roll their head 90 degrees ( return to original position, affected ear down)
# Reposition patient so that they are facing up into sitting position


*Dix-Hallpike Maneuver:&nbsp;http://www1.imperial.ac.uk/resources/6891997E-5A13-41E7-875B-5982A5F07A87/<ref name="Dix">Imperial College London. Dix-Hallpike Maneuver. [Video: Website] http://www1.imperial.ac.uk/resources/6891997E-5A13-41E7-875B-5982A5F07A87 (Accessed November3 2012).</ref>&nbsp;
=== Gufoni Maneuver ===
Treatment for horizontal/lateral canal BPPV
# Patient taken from sitting to side-lying on affected or unaffected side
#* Geotropic nystagmus: unaffected
#* Apogeotropic: affected
# Turn patient head quickly towards ground (45-60 degrees), hold in this position for 2 minutes
# Patient returns to sitting with head maintained in that position
=== Habituation Techniques<ref name="AHRF" /> ===
* Avoid quick spins or movements that provoke vertigo
* Sleep in semi-recumbent position for next 2 nights following Epley's technique (use a recliner or stack of pillows)
* Avoid sleeping on affected side
* Try keep head upright during day and avoid all supine activities
* After being conservative for a week, start to place head (in controlled environments) in vertigo provoking positions
==Vestibular Rehabilitation Exercises==
Vestibular rehabilitation exercises are commonly included in the treatment of BPPV and are designed to train the brain to use alternative visual and proprioceptive cues to maintain balance and gait.<ref name="Swartz">Swartz R, Longwell P. Treatment of Vertigo. American Academy of Family Physicians. 2005; 71: 1115-1122</ref> It has been shown that these exercises improved nystagmus, postural control, movement-provoked dizziness, the ability to perform activities of daily living independently, and levels of distress.<ref name="Swartz" />&nbsp;While no single vestibular rehabilitation exercise has been shown to reduce the symptoms of BPPV, a program of therapies that can include self-administered repositioning maneuvers, gaze stabilization exercises, falls prevention training, and patient education may be beneficial in reducing the symptoms of BPPV and improve quality of life.<ref name="Bhattacharyya2">Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology-Head and Neck Surgery 2008;139(5):S47-S81.</ref>


<u>Treatment Links</u>  
The evidence supporting the efficacy of vestibular rehabilitation exercises in reducing symptoms of BPPV is lacking.<ref name="Bhattacharyya2" /> Steenerson et al.<ref name="Steenerson">Steenerson R, Cronin G. Comparison of the canalith repositioning procedure and vestibular habituation training in forty patients with benign paroxysmal positional vertigo. American Academy of Otolaryngology- Head and Neck Surgery Foundation. 1996; 114: 61-64.</ref>, found that Epley’s maneuver administered by a health care practitioner was a better treatment technique than vestibular rehabilitation exercises. Vestibular exercises were, however deemed to be better than no treatment at all. No single form of vestibular rehabilitation exercise has been found to be superior and exercises appear to have a greater effect when performed together, rather than as single exercises alone.<ref name="Bhattacharyya2" />
===Cawthorne-Cooksey Exercises===
The Cawthorne-Cooksey exercises aim to relax the neck and shoulder muscles, train eyes to move independently of the head, and to practice balance and head movements that cause dizziness.<ref name="Brain">Brain and Spine Foundation. Vestibular Rehabilitation Exercises: A Fact Sheet for Patients and Carers. http://www.brainandspine.org.uk/information/publications/brain_and_spine_booklets/vestibular_rehabilitation_exercises/index.html (Accessed October 12 2012).</ref> The exercises consist of a series of eye, head, and body movements, in increasing difficulty, which aim to provoke symptoms.<ref name="Bhattacharyya2" /> The goal of these exercises is to fatigue the vestibular response and force the central nervous system to compensate by habituation to the stimulus.<ref name="Bhattacharyya2" />
====A video description of the Cawthorne-Cooksey Exercises====
{{#ev:youtube|NXyg9n3nFQk}}&nbsp;<ref name="Cawthorne">Vestibular Rehabilitation Exercises. [Video: Website]. http://www.youtube.com/watch?v=NXyg9n3nFQk. 2011. (Accessed October 30 2012).</ref>
===Brandt-Daroff Exercises===
The Brandt-Daroff exercises are a series of particle repositioning exercises that can be performed without a qualified health professional present and are easily taught to the patient.<ref name="Brain" />&nbsp;While beneficial, these exercises are more time consuming than other forms of treatment. They are completed by the patient in bed, 3 sets a day for 2 weeks and aim to help reduce the chance of reoccurrence of BPPV and promote the loosening of canaliths.<ref name="Bhattacharyya2" /> Radke et al.<ref name="Radke">Radke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology. 1999; 53: 1358-1360.</ref> found that when these exercises are performed as the only form of treatment, they were successful at relieving the symptoms of BPPV in only 25% of individuals after one week of administration. The Brandt-Daroff exercises have been found to be a beneficial adjunct treatment in the symptomatic relief of BPPV.<ref name="Bhattacharyya2" />


*Epley’s Maneuver: http://www.youtube.com/watch?v=7ZgUx9G0uEs<ref name="Epley" />
The Brandt-Daroff exercises may be summarized in the following steps (see Figure 7):[[Image:Brandt.JPG|thumb|right|Figure 7. The Brandt-Daroff Exercises]]
*Semont Liberatory Maneuver: http://www.youtube.com/watch?v=A72UjulJSzE<ref name="Semont" />
*Step 1 - Have the patient sit on the edge of the bed and turn their head 45° to one side


*Cawthorne-Cooksey Exercises:
*Step 2 - Quickly have the patient lie down on the opposite side that their head is facing


#http://foi.avon.nhs.uk/Download.aspx?r=1&amp;did=7775&amp;f=CawthorneCookseyExercises-3.pdf
*Step 3 - Have the patient hold this position for 30 seconds
#http://www.youtube.com/watch?v=NXyg9n3nFQk<ref name="Cawthorne" />


*Brandt-Daroff Exercises:&nbsp;http://www.youtube.com/watch?v=CTZfIv165sY<ref name="Brandt" />
*Step 4 - Return to the sitting position


<u>Additional Videos</u>  
*Step 5 - Repeat steps 1-4 while facing the opposite direction, alternating until 6 repetitions have been completed.<ref name="Brain" />
====A video demonstration of the Brandt-Daroff Exercises====
{{#ev:youtube|CTZfIv165sY}}&nbsp;<ref name="Brandt">Brandt-Daroff Exercises for BPPV Dr. Michael Teixido. [Video: Website]. http://www.youtube.com/watch?v=CTZfIv165sY. 2011. (Accessed October 30 2012).</ref>
== Medical Management  ==


*Diagnosis and Treatment: http://www.youtube.com/watch?v=iOJOArGmepM<ref>How to Diagnose and Treat Horizontal Canal BPPV EDITED. [Video:Website] http://www.youtube.com/watch?v=iOJOArGmepM. 2012. (Accessed October 15 2012).</ref>
BPPV is a benign diagnosis so treatment is not always needed. Occasionally, BPPV can resolve itself with no intervention<ref name="Nguyen">Nguyen- Huynh, A. T., MD PhD. (2012). Evidence-Based Practice: Management of Vertigo.Otolaryngeol Clin North Am. ,45(5), 925-940. doi:10.1016/j.otc.2012.06.001</ref>.
*Nystagmus Pattern for Right BPPV:&nbsp;http://www1.imperial.ac.uk/resources/B1C72EE9-92DC-41DC-B802-D3B779FE8873/<ref>Imperial College London. Nystagmus Pattern for Right BPPV. [Video:Website] http://www1.imperial.ac.uk/resources/B1C72EE9-92DC-B802-D3B779FE8873/. (Accessed November 2 2012).</ref>


<u>Additional Links for BPPV</u>  
Surgery<ref name="Nguyen" />:
* Singular Nerve Neurectomy
* Posterior Canal Occlusion
Medications:
* There are no medications that directly treat BPPV
* Antivert, Meclizine and vestibular suppressants can be prescribed to treat dizziness, nausea and other symptoms related to BPPV<ref name="Cohen">Cohen, H. S., &amp; Sangi-Haghpeykar, H. (2010). Canalith repositioning variations for benign paroxysmal positional vertigo.Otolaryngology - Head and Neck Surgery,143(3), 405-412. doi:10.1016/j.otohns.2010.05.022</ref>
<br> Drug treatments are not presently recommended for BPPV and bilateral vestibular paresis.


*NHS- Clinical Knowledge Summaries:&nbsp;http://www.cks.nhs.uk/benign_paroxysmal_positional_vertigo/management/scenario_diagnosis/diagnosis/hallpike_manoeuvre#471758006
*Prophylactic agents (L-channel calcium channel antagonists, tricyclic antidepressants, beta-blockers) are the mainstay of treatment for migraine-associated vertigo.
*Patient.co.uk:&nbsp;[http://www.patient.co.uk/health/Benign-Paroxysmal-Positional-Vertigo.htm http://www.patient.co.uk/health/Benign-Paroxysmal-Positional-Vertigo.htm]
*In individuals with stroke or other structural lesions of the brainstem or cerebellum, an eclectic approach incorporating trials of vestibular suppressants and physical therapy is recommended.
*Psychogenic vertigo occurs in association with disorders such as panic disorder, anxiety disorder and agoraphobia. Benzodiazepines are the most useful agents here.
*Undetermined and ill-defined causes of vertigo make up a large remainder of diagnoses. An empirical approach to these patients incorporating trials of medications of general utility, such as benzodiazepines, as well as trials of medication withdrawal when appropriate, physical therapy and psychiatric consultation is suggested<ref name="TC">Hain TC, Uddin M., Pharmacological treatment of vertigo.CNS Drugs. 2003;17(2):85-100.</ref>.
== Outcome Measures  ==
There are many outcome measures used when treating patients with vertigo, such as:<ref name="Cohen" /><ref name="Mas">Maslovara, S. (2014). Importance of accurate diagnosis in benign paroxysmal positional vertigo (BPPV) therapy.Med Glas,11(2).</ref>
* [http://www.rehab.msu.edu/_files/_docs/Dizziness_Handicap_Inventory.pdf Dizziness Handicap Inventory] (DHI)
* [[Dynamic Gait Index]] (DGI)
* [http://geriatrictoolkit.missouri.edu/vest/CTSIB.pdf Clinical Test of Sensory Interaction in Balance] (CTSIB)
* Activities-specific Balance Confidence Scale
* Vertigo Intensitu
* Vertigo Frequency
* Vestibular Disorders Activities of Daily Living Scale
== Resources  ==
* [http://www.dizziness-and-balance.com/disorders/bppv/bppv.html Benign Paroxysmal Positional Vertigo] (for the clinician and patient)
* [http://www.entnet.org/Practice/upload/BPPV-guideline-final-journal.pdf Clinical Practice Guideline: BPPV] (for the clinician)
* [http://physicaltherapyjournal.com/content/90/5/663.short Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review from PT Journal May 2010]


&nbsp;
== References  ==


= References  =
<references /> <br>


<references />
[[Category:Bellarmine_Student_Project]]
[[Category:Neuro-otology]]
[[Category:Assessment]]
[[Category:Neurological - Assessment and Examination]]
[[Category:Neurological - Conditions]]
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
[[Category:Primary Contact]]
[[Category:Vestibular System]]
[[Category:Vestibular - Assessment and Examination]]

Latest revision as of 14:32, 7 March 2024

Original Editors - Steve Blakely

Top Contributors - Chris Milne, Lee Marshall, Lauren Russell, Brían Lillis, Kim Jackson, Kai A. Sigel, Nikhil Benhur Abburi, Admin, Anna Thommasen, 127.0.0.1, Ahmed M Diab, Scott Buxton, Karen Wilson, Candace Goh, Lucinda hampton, Habibu Salisu Badamasi, Tony Lowe, Wendy Walker and Melanie Reis

Definition/Description[edit | edit source]

Vertigo.jpeg

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo, which is a symptom of the condition[1]. Though not fully understood, BPPV is thought to arise due to the displacement of otoconia (small crystals of calcium carbonate) from the maculae[1] of the inner ear into the fluid-filled semicircular canals. These semicircular canals are sensitive to gravity and changes in head position can be a trigger for BPPV[2]. The posterior canal is the most commonly affected site, but the superior and horizontal canals can be affected as well[3]. It should be noted that the superior canal is sometimes also referred to as the anterior canal and the horizontal canal is sometimes referred to as lateral canal.

The peripheral vestibular labyrinth contains sensory receptors in the form of ciliated hairs in the three semicircular canals and in the ear’s otolithic organs. They respond to movement and relay signals via the eighth cranial nerve. Visual perception such as gravity, position, and movements also receive signals from somatosensory receptors in the peripheral vestibules. With the displacement of the otoconia into the semicircular canals, these delicate feedback loops relay conflicting signals that can result in any symptom related to BPPV[4].

BPPV can be classified as cupulolithiasis and canalithiasis. Cupulolithiasis is when the otoconia are adhered to the cupula, whilst canalithiasis is when the otoconia are free floating in the canal. Additionally, the type of nystagmus that a patient may display can be classified as geotropic or apogeotropic. Geotropic describes the nystagmus as a horizontal beat towards the ground. Apogeotropic describes the nystagmus as a horizontal beat towards the ceiling[5].


[6]

Clinically Relevant Anatomy[edit | edit source]

Interior View of Labyrinth

Benign paroxysmal positional vertigo (BPPV) is a specific type of vertigo that is brought on by a change in position of the head with respect to gravity. This disorder is caused by problems in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in the position of the head.[7]

The vestibular system monitors the motion and position of the head in space by detecting angular and linear acceleration. The 3 semicircular canals in the inner ear detect angular acceleration and are positioned at near right angles to each other. Each canal is filled with endolymph and has a swelling at the base termed the ampulla. The ampulla contains the cupula, a gelatinous mass with the same density as endolymph, which in turn is attached to polarized hair cells. Movement of the cupula by endolymph can cause either a stimulatory or an inhibitory response, depending on the direction of motion and the particular semicircular canal[8]. There is a vestibular apparatus within each ear so under normal circumstances, the signals being sent from each vestibular system to the brain should match, confirming that the head is indeed rotating to the right, for example.

Within the labyrinth of the inner ear lie collections of calcium crystals known as otoconia. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position)[8]. When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris (colloquially ear rocks or crystals) within the affected semicircular canal causes abnormal (pathological) fluid endolymph displacement in the affected ear. This fluid displacement will send a signal to the brain indicating that rotational movement is occuring. However, the vestibular apparatus in the unaffected ear will not be transmitting the same signal because there are no loose otoconia triggering the hair cells abnormally. This resultant mismatch in signals coming from the right and left vestibular systems lead to the sensation of vertigo. This more common condition is known as canalithiasis. Vertigo associated with this condition will be of short duration, even if the person with the condition stays in the provocative position, because the endolymph and otoconia will quickly come to a rest so the hair cells will no longer be displaced and triggering the signal to the brain.

In rare cases, the crystals themselves can adhere to a semicircular canal cupula rendering it heavier than the surrounding endolymph. Upon reorientation of the head relative to gravity, the cupula is weighted down by the dense particles thereby inducing an immediate and maintained excitation of semicircular canal afferent nerves. This condition is termed cupulolithiasis. Vertigo associated with this condition will not resolve until the head is moved out of the provocative position because even when the endolymph comes to a rest, the adhered otoconia will continue to displace the hair cells and trigger the signal of movement to the brain.

It can be triggered by any action which stimulates the posterior semi-circular canal which may be:

  • Tilting the head
  • Rolling over in bed
  • Looking up or under
  • Sudden head motion

BPPV may be made worse by any number of modifiers which may vary between individuals:

  • Changes in barometric pressure - patients often feel symptoms approximately two days before rain or snow [9]
  • Lack of sleep (required amount of sleep may vary widely)
  • Stress

Aetiology/Causes[edit | edit source]

The most common cause of BPPV is idiopathic. However, the vestibular system of the inner ear can also undergo degenerative changes as one ages which can attribute to a potential cause of BPPV. Under age 50, head injury is a common cause. Vestibular viruses and Meniere’s disease also play a role. BPPV can also be a result of surgery due to prolonged supine positioning and possible trauma to the inner ear[10].

Risk factors include[2][11][12]:

  • Female gender
  • falls
  • Hypertension (HTN)
  • Hyperlipidemia
  • Cerebrovascular disease
  • Menopause
  • Allergies
  • Migraine
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Surgical procedure such as a cochlear implant
  • Infection

Prevalence [edit | edit source]

  • Dizziness is the complaint in 5.6 million clinical visits in the United States per year, and between 17 and 42 percent of these patients are diagnosed with BPPV[13].
  • Female to male ratio is 3:1[11]
  • The recurrence rate for individuals at one year following initial bout of BPPV is 15% and at 5 years the recurrence rate is 37-50%[14].
  • Individuals with a clinical diagnosis of anxiety are 2.7 times more likely to develop BPPV[11].
  • Unilateral posterior canal is the most commonly affected canal in BPPV with 90% of all BPPV diagnosis[15].
  • Unilateral horizontal canal affects 5-15% of all BPPV diagnosis. Within a horizontal canal diagnosis, 2/3 of the cases are geotropic while 1/3 of the cases are apogeotropic[15].
  • Anterior canal affects 1-2% of all BPPV diagnoses, which is the least common[15].
  • The lifetime prevalence is 2.4 percent[13].

Clinical Presentation[edit | edit source]

The signs and symptoms of BPPV are often transient, with symptoms commonly lasting less than one minute (paroxysmal).[16] Episodes of BPPV can resolve after a few weeks or months, but may reappear at a later time. Screening for BPPV in all people with falls risk, whether dizzy or not, is important to detect all cases of BPPV.[17]

The possible reasons why people test positive for Signs and symptoms may include:[16]

  • Vertigo: Spinning sensation (not lightheadedness or feeling off-balance.)
    • Short duration (Paroxysmal): Lasts only seconds to minutes (usually less than 60 seconds)[18]
    • Positional in onset: only induced by a change in position
    • Nausea
  • Visual disturbance: It may be difficult to read or see during an attack due to the associated nystagmus.
    • Pre-Syncope (feeling faint) or Syncope (fainting)
    • Vomiting is uncommon, but possible.
  • Loss of balance Symptoms are considered:
    • Mild: inconsistent positional vertigo
    • Moderate: frequent positional vertigo attacks with disequilibrium between vertigo attacks
    • Severe: vertigo with most head movements, which can appear as continuous vertigo[14]. Individuals with BPPV can have symptoms that last days, weeks, months or years before it is resolved[14].

Research suggests there is a definite correlation between cognitive skills and balance in women patients affected with chronic peripheral vestibulopathy[19].

  • Signs
    • Rotatory (torsional) nystagmus, where the top of the eye rotates towards the affected ear in a beating or twitching fashion

Associated Co-morbidities[edit | edit source]

There are conditions that appear to more prevalent in patients that experience BPPV, for example:[2][5]

Differential Diagnosis[edit | edit source]

Otological disorders include:[13]
  • Meniere's disease
  • Vestibular neuritis
  • Labyrinthitis
  • Superior canal dehiscence syndrome
  • Post-traumatic vertigo
Other possible causes are:[13]
  • Anxiety or panic disorders
  • Cervicogenic dizziness
  • Medication side effects
  • Postural hypotension
Neurological disorders include:[13]
  • Migraine-associated dizziness
  • Vertebrobasilar insufficiency
  • Demyelinating diseases

Contraindications[edit | edit source]

Physical therapy is not appropriate for unstable vestibular disorders such as

  • Meniere's disease
  • Uncontrolled migraine
  • Perilymph Fistula (PLF)
  • Unresolved Superior Semicircular Canal Dehiscence (SSCD)
  • Sudden loss of hearing
  • Ringing in one or both ears

Diagnostic Procedures[edit | edit source]

BPPV can easily be diagnosed and treated through simple clinic-based procedures.[20] In the past, a wide variety of different tests and procedures have been explored for diagnosis of BPPV, but many of these techniques have been discredited in recent years. Currently the primary method of diagnosis involves in-depth subjective screening, followed by physical investigations and diagnostic manoeuvres to confirm BPPV. These methods of diagnosis have been shown to be clinically appropriate, simple to perform, and cost effective.[7] Early diagnosis of BPPV is important and may help improve quality of life for patients and reduce the risk of more serious injury. Techniques may be easily incorporated into routine physiotherapy assessment and should be considered for any patients presenting with symptoms of dizziness and vertigo. The condition is diagnosed from patient history (feeling of vertigo with sudden changes in positions) and by performing a positional test. Different positional test exist. The exact positional test used to confirm the presence of BPPV will depend on which semicircular canal is involved.

Subjective Assessment[edit | edit source]

The subjective assessment is the first step in clinically diagnosing BPPV.  Any complaints of dizziness necessitate the taking of a detailed patient history and further investigation of the symptoms.[21] Patient history alone is insufficient to accurately diagnose BPPV, but patient description of vertigo can give a very good indication of the cause.[7] However, people with risk of falls without symptoms of dizziness should be assessed. [17]Clinicians should look out for patients describing sudden severe attacks of vertigo or dizziness, precipitated by head position and movement.[22] The most common movements thought to provoke symptoms are rolling over in bed, extension of the neck to look up, and bending forward.[22] Patients typically describe their vertigo as a rotational or spinning sensation provoked by these movements.[7]

Different studies have aimed to identify and validate useful questions when suspecting a diagnosis of BPPV. There are however no current guidelines for appropriate BPPV screening questions. Some important aspects of the condition have been identified which should be explored to rule out other causes[18]. Clinicians should be asking patients questions regarding:

1. Type of dizziness and vertigo
2. Duration of dizziness and vertigo
3. Precipitating and exacerbating factors
4. Accompanying symptoms

Physical Assessment[edit | edit source]

If details of the subjective assessment and patient history indicate BPPV, then further physical investigation is needed to confirm a diagnosis. Physical diagnosis maneuvers involve a series of movements which aim to provoke nystagmus and symptoms of vertigo. The two diagnostic maneuvers used clinically are the Dix-Hallpike maneuver and the Supine Roll Test. A positive result on either of these tests indicates a diagnosis of BPPV. They also help to distinguish the type of BPPV and identify the ear involved.

Dix Hall Pike[edit | edit source]

The most commonly used test is Dix-Hallpike which assesses involvement of the posterior canal (the most commonly affected semicircular canal).[23] The test involves turning the head 45 degrees to the side being tested and then quickly moving from a seated to a supine position with the head declined 30 degrees below the trunk. The test must be performed quickly to ensure sufficient displacement of the endolymp and otoconia to provoke the expected symptoms. The test is considered positive for canalithiasis of the posterior canal if vertigo is provoked and nystagmus is observed, both of which should be of short-duration for canalithiasis. The direction of the observed nystagmus should be consistent with the canal being assessed. For the posterior canal, nystagmus should be up-beating and torsional in an ipsilateral direction (if testing the affected side. If the left side is affected but the test is performed with the head turned to the right, the nystagmus would be up-beating and torsional to the right).

Horizontal Roll Test[edit | edit source]

This test is to assess the horizontal semicircular canal

  1. Patient is supine. Examiner flexes the cervical spine 20-30 degrees.
  2. Examiner quickly rotates the head to the right approximately 45 degrees. Hold for 30 seconds or until nystagmus and/or other symptoms have subsided
  3. Slowly return patient's head to midline.
  4. Next, quickly rotate patient's head to the left approximately 45 degrees.Hold for 30 seconds or until nystagmus and/or other symptoms have subsided.
  5. Slowly return patient's head to midline.
  6. Test is positive for nystagmus of other symptomatic complaints during the test. The patient may be positive on both sides. If this happens, the side that has more intense symptoms is considered the affected side.<be>
[24]
[25]

Head Pitch Test (“Bow and Lean” Test)[edit | edit source]

This test is used to assess unilateral horizontal canal BPPV[15]

  1. Patient is seated
  2. Examiner first bends the patient’s head forward 30 degrees. Reassess nystagmus. Patient’s nystagmus should disappear because the horizontal canal is now in a true horizontal position.
  3. Examiner then bends the patient’s head forward to 60 degrees. Reassess nystagmus. A fast paced nystagmus may be present. If the nystagmus is being caused by the otoconia moving, the nystagmus will beat toward the affected ear. If the otoconia is attached to the cupula, the nystagmus will beat towards the unaffected ear.
  4. Examiner bends the patient’s head backwards 30 degrees. Reassess nystagmus. May see an increase in nystagmus due to the horizontal canal being vertical

The nystagmus associated with BPPV has several important characteristics which differentiate it from other types of nystagmus.

  • Positional: the nystagmus occurs only in certain positions
  • Latency of onsent: there is a 5-10 second delay prior to onset of nystagmus
  • Nystagmus lasts for 5-30 seconds
  • Visual fixation does not suppress nystagmus due to BPPV
  • Both a rotatory and upbeat vertical components are present
  • The nystagmus beats in a geotrophic (top of the eye towards the ground fashion
  • Repeated Dix-Hallpike maneuvers cause the nystagmus to fatigue or disappear temporarily

If nystagmus and vertigo are sustained, cupulolithiasis or a potentially more central cause of vertigo should be considered. Patient history and other neurological tests can help to rule out a more serious central cause.

Physiotherapy Management[edit | edit source]

Research review implies that the posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment, and the choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient.[26] Two treatments have been found effective for relieving symptoms of posterior canal BPPV:

  1. Canalith repositioning procedure (Epley maneuver)
    • Employs gravity to move calcium build-up that causes the condition
    • Can also be performed by trained otolaryngologists, neurologisists, chiropractors or audiologists
  2. Liberatory or Semont maneuver
[27]
[28]


Epley Maneuver[edit | edit source]

  1. Patient starts in long sitting, head rotated 45 degrees to affected side
  2. Patient rapidly reclined to supine position with neck slightly extended. Hold position for 30 seconds, or until nystagmus and dizziness subside
  3. Rotate head 90 degrees to opposite side. Hold position for 20 seconds, or until nystagmus and dizziness subside
  4. Patient rotated 90 degrees from supine to side-lying. Hold position for 20 seconds, or until nystagmus and dizziness subside
  5. Bring patient up into short-sitting
    May need to complete this maneuver 1 to 3 visits complete resolution of symptoms.

Semont Maneuver[edit | edit source]

  1. Patient sits in short sitting, head rotated 45 degrees towards unaffected ear[14]
  2. Examiner places one hand under the bottommost shoulder while the other hand supports the neck
  3. Patient rapidly moves into side-lying to the affected side (face should be oriented towards ceiling). Hold this position for 30 seconds
  4. Without any head movement, patient is to move to side-lying on opposite side of the body (face oriented towards bed). Hold this position for 30 seconds


[29]
[30]

Lempert Maneuver[edit | edit source]

Treatment for horizontal/lateral canal BPPV

  1. Patient lie supine on examination table, affected ear down
  2. Quickly turn the head 90 degrees towards unaffected side facing up
  3. Wait 15-20 seconds between each head turn
  4. Turn the head 90 degrees so affected ear is up
  5. Have patient tuck arms to chest, roll patient into prone
  6. Have patient turn on side as you roll their head 90 degrees ( return to original position, affected ear down)
  7. Reposition patient so that they are facing up into sitting position

Gufoni Maneuver[edit | edit source]

Treatment for horizontal/lateral canal BPPV

  1. Patient taken from sitting to side-lying on affected or unaffected side
    • Geotropic nystagmus: unaffected
    • Apogeotropic: affected
  2. Turn patient head quickly towards ground (45-60 degrees), hold in this position for 2 minutes
  3. Patient returns to sitting with head maintained in that position

Habituation Techniques[10][edit | edit source]

  • Avoid quick spins or movements that provoke vertigo
  • Sleep in semi-recumbent position for next 2 nights following Epley's technique (use a recliner or stack of pillows)
  • Avoid sleeping on affected side
  • Try keep head upright during day and avoid all supine activities
  • After being conservative for a week, start to place head (in controlled environments) in vertigo provoking positions

Vestibular Rehabilitation Exercises[edit | edit source]

Vestibular rehabilitation exercises are commonly included in the treatment of BPPV and are designed to train the brain to use alternative visual and proprioceptive cues to maintain balance and gait.[31] It has been shown that these exercises improved nystagmus, postural control, movement-provoked dizziness, the ability to perform activities of daily living independently, and levels of distress.[31] While no single vestibular rehabilitation exercise has been shown to reduce the symptoms of BPPV, a program of therapies that can include self-administered repositioning maneuvers, gaze stabilization exercises, falls prevention training, and patient education may be beneficial in reducing the symptoms of BPPV and improve quality of life.[32]

The evidence supporting the efficacy of vestibular rehabilitation exercises in reducing symptoms of BPPV is lacking.[32] Steenerson et al.[33], found that Epley’s maneuver administered by a health care practitioner was a better treatment technique than vestibular rehabilitation exercises. Vestibular exercises were, however deemed to be better than no treatment at all. No single form of vestibular rehabilitation exercise has been found to be superior and exercises appear to have a greater effect when performed together, rather than as single exercises alone.[32]

Cawthorne-Cooksey Exercises[edit | edit source]

The Cawthorne-Cooksey exercises aim to relax the neck and shoulder muscles, train eyes to move independently of the head, and to practice balance and head movements that cause dizziness.[34] The exercises consist of a series of eye, head, and body movements, in increasing difficulty, which aim to provoke symptoms.[32] The goal of these exercises is to fatigue the vestibular response and force the central nervous system to compensate by habituation to the stimulus.[32]

A video description of the Cawthorne-Cooksey Exercises[edit | edit source]

 [35]

Brandt-Daroff Exercises[edit | edit source]

The Brandt-Daroff exercises are a series of particle repositioning exercises that can be performed without a qualified health professional present and are easily taught to the patient.[34] While beneficial, these exercises are more time consuming than other forms of treatment. They are completed by the patient in bed, 3 sets a day for 2 weeks and aim to help reduce the chance of reoccurrence of BPPV and promote the loosening of canaliths.[32] Radke et al.[36] found that when these exercises are performed as the only form of treatment, they were successful at relieving the symptoms of BPPV in only 25% of individuals after one week of administration. The Brandt-Daroff exercises have been found to be a beneficial adjunct treatment in the symptomatic relief of BPPV.[32]

The Brandt-Daroff exercises may be summarized in the following steps (see Figure 7):

Figure 7. The Brandt-Daroff Exercises
  • Step 1 - Have the patient sit on the edge of the bed and turn their head 45° to one side
  • Step 2 - Quickly have the patient lie down on the opposite side that their head is facing
  • Step 3 - Have the patient hold this position for 30 seconds
  • Step 4 - Return to the sitting position
  • Step 5 - Repeat steps 1-4 while facing the opposite direction, alternating until 6 repetitions have been completed.[34]

A video demonstration of the Brandt-Daroff Exercises[edit | edit source]

 [37]

Medical Management[edit | edit source]

BPPV is a benign diagnosis so treatment is not always needed. Occasionally, BPPV can resolve itself with no intervention[38].

Surgery[38]:

  • Singular Nerve Neurectomy
  • Posterior Canal Occlusion

Medications:

  • There are no medications that directly treat BPPV
  • Antivert, Meclizine and vestibular suppressants can be prescribed to treat dizziness, nausea and other symptoms related to BPPV[39]


Drug treatments are not presently recommended for BPPV and bilateral vestibular paresis.

  • Prophylactic agents (L-channel calcium channel antagonists, tricyclic antidepressants, beta-blockers) are the mainstay of treatment for migraine-associated vertigo.
  • In individuals with stroke or other structural lesions of the brainstem or cerebellum, an eclectic approach incorporating trials of vestibular suppressants and physical therapy is recommended.
  • Psychogenic vertigo occurs in association with disorders such as panic disorder, anxiety disorder and agoraphobia. Benzodiazepines are the most useful agents here.
  • Undetermined and ill-defined causes of vertigo make up a large remainder of diagnoses. An empirical approach to these patients incorporating trials of medications of general utility, such as benzodiazepines, as well as trials of medication withdrawal when appropriate, physical therapy and psychiatric consultation is suggested[40].

Outcome Measures[edit | edit source]

There are many outcome measures used when treating patients with vertigo, such as:[39][41]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Shim, D. B., Song, C. E., Jung, E. J., Ko, K. M., Park, J. W., & Song, M. H. (2014). Benign Paroxysmal Positional Vertigo with Simultaneous Involvement of Multiple Semicircular Canals.Korean Journal of Audiology,18(3), 126. doi:10.7874/kja.2014.18.3.126
  2. ↑ 2.0 2.1 2.2 Ogun OA, Janky KL, Cohn ES, Büki B, Lundberg YW. Gender-Based Comorbidity in Benign Paroxysmal Positional Vertigo. PLoS ONE. 2014;9(9). doi:10.1371/journal.pone.0105546.
  3. ↑ Timothy C. Hain, MD, BENIGN PAROXYSMAL POSITIONAL VERTIGO, site: http://www.dizziness-and-balance.com/disorders/bppv/bppv.html , Page last modified: February 3, 2013
  4. ↑ Sonia Sandhaus, Stop the spinning: Diagnosing and managing vertigo. Nurse Practitioner. 2002 Aug 1;27(8): 11-23.
  5. ↑ 5.0 5.1 Maia FZE. New treatment strategy for apogeotropic horizontal canal benign paroxysmal positional vertigo. Audiology Research. 2016;6(2). doi:10.4081/audiores.2016.163.
  6. ↑ UPMC. What Is Benign Paroxysmal Positional Vertigo? . Available from: https://www.youtube.com/watch?v=1AfvNsaQnTE [last accessed 26/8/2022]
  7. ↑ 7.0 7.1 7.2 7.3 Neil Bhattacharyya, Reginald F. Baugh, Laura Orvidas, David Barrs, Leo J. Bronston, Stephen Cass, Ara A. Chalian, Alan L. Desmond, Jerry M. Earll, Terry D. Fife, Drew C. Fuller, MPH, James O. Judge, Nancy R. Mann, Richard M. Rosenfeld, Linda T. Schuring, Robert W. P. Steiner, Susan L. Whitney, and Jenissa Haidari. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology–Head and Neck Surgery, 2008, 139, S47-S81
  8. ↑ 8.0 8.1 Lorne S. Parnes, Sumit K. Agrawal and Jason Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. September 30, 2003; 169 (7)
  9. ↑ Korpon JR, Sabo RT, Coelho DH. Barometric pressure and the incidence of benign paroxysmal positional vertigo. American Journal of Otolaryngology. 2019 Sep 1;40(5):641-4. [1]
  10. ↑ 10.0 10.1 American Hearing Research Foundation: Benign Paroxysmal Positional Vertigo (BPPV). http://www.american-hearing.org/disorders/benign-paroxysmal-positional-vertigobppv/
  11. ↑ 11.0 11.1 11.2 Chen, Z., Chang, C., Hu, L., Tu, M., Lu, T., Chen, P., & Shen, C. (2016). Increased risk of benign paroxysmal positional vertigo in patients with anxiety disorders: a nationwide population-based retrospective cohort study.BMC Psychiatry,16(1). doi:10.1186/s12888-016-0950-2
  12. ↑ Gaur S, Awasthi SK, Bhadouriya SKS, Saxena R, Pathak VK, Bisht M. Efficacy of Epley’s Maneuver in Treating BPPV Patients: A Prospective Observational Study. International Journal of Otolaryngology. 2015;2015:1-5. doi:10.1155/2015/487160.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Bhattacharyya N, Baugh R, Orvidas L, Barrs D, Bronston L, Haidari J, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology--Head And Neck Surgery: Official Journal Of American Academy Of Otolaryngology-Head And Neck Surgery, 2008, Nov; 139(5 Suppl 4): S47-S81
  14. ↑ 14.0 14.1 14.2 14.3 Hornibrook, J. (2011). Benign Paroxysmal Positional Vertigo (BPPV): History, Pathophysiology, Office Treatment and Future Directions.International Journal of Otolaryngology,2011, 1-13. doi:10.1155/2011/835671
  15. ↑ 15.0 15.1 15.2 15.3 Balatsouras DG, Koukoutsis G, Ganelis P, Korres GS, Kaberos A. Diagnosis of Single- or Multiple-Canal Benign Paroxysmal Positional Vertigo according to the Type of Nystagmus. International Journal of Otolaryngology. 2011;2011:1-13. doi:10.1155/2011/483965.
  16. ↑ 16.0 16.1 Musat J. The Clinical Characteristics and Treatment of Benign Paraoxysmal Positional Vertigo in the Elderly. Romanian Journal of Neurology 2010;9(4):189-192.
  17. ↑ 17.0 17.1 Susan Hyland, Lyndon J. Hawke & Nicholas F. Taylor (24 Feb 2024):Benign paroxysmal positional vertigo without dizziness is common in people presenting to falls clinics,Disability and Rehabilitation DOI:10.1080/09638288.2024.2320271
  18. ↑ 18.0 18.1 Strupp M, Dieterich M, Brandt T. The Treatment and Natural Course of Peripheral and Central Vertigo. Deutsches Ärzteblatt International . 110(29):505-516.
  19. ↑ Coelho AR, Perobelli JL, Sonobe LS, Moraes R, de Carneiro Barros CG, de Abreu DC. Severe Dizziness Related to Postural Instability, Changes in Gait and Cognitive Skills in Patients with Chronic Peripheral Vestibulopathy. International Archives of Otorhinolaryngology. 2020 Jan;24(01):e38-45.
  20. ↑ Balasouras DG, Koukoutsis G, Ganelis P, Korres GS, Kaberos A. Diagnosis of single- or multiple-canal benign paroxysmal positional vertigo according the type of nystagmus. International Jounral of Otalaryngology. 2011; 1-13.
  21. ↑ Strupp M and Brandt T. Diagnosis and treatment of vertigo and dizziness. Dtsch Arztebl Int. 2008; 105(10): 173-180.
  22. ↑ 22.0 22.1 Parnes L, Agrawal S, Atlas J. Diagnosis and Management of Benign Paroxysmal Positional Vertigo (BPPV) 2003; 169(7): 681-693.
  23. ↑ Lorne S. Parnes, Sumit K. Agrawal and Jason Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. September 30, 2003; 169 (7)
  24. ↑ Ascension Via Christi. Dix Hallpike Maneuver. Available from: https://www.youtube.com/watch?v=R-uVlxWDu4k [last accessed 14/7/2022]
  25. ↑ Ascension Via Christi. Supine Roll Maneuver. Available from: https://www.youtube.com/watch?v=U3SGJfjwJaw [last accessed 14/7/2022]
  26. ↑ Curr Treat Options Neurol. 2019 Dec 5;21(12):66. doi: 10.1007/s11940-019-0606-x.
  27. ↑ AquacarePT. How to perform the epley maneuver at home for BPPV. Available from: https://www.youtube.com/watch?v=VtJB5Vx7Xqo [last accessed 26/8/2022]
  28. ↑ Michigan Medicine. Liberatory Semont Maneuver for Right BPPV. Available from: https://www.youtube.com/watch?v=A72UjulJSzE&t=2s [last accessed 26/8/2022]
  29. ↑ Ascension Via Christi. Barbeque Roll Lempert maneuver. Available from: https://www.youtube.com/watch?v=ufD_tcSx5dQ [last accessed 26/8/2022]
  30. ↑ Gelreziekenhuizen. Gufoni manoeuvre. Available from: https://www.youtube.com/watch?v=gTkZs0EcREY [last accessed 26/8/2022]
  31. ↑ 31.0 31.1 Swartz R, Longwell P. Treatment of Vertigo. American Academy of Family Physicians. 2005; 71: 1115-1122
  32. ↑ 32.0 32.1 32.2 32.3 32.4 32.5 32.6 Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology-Head and Neck Surgery 2008;139(5):S47-S81.
  33. ↑ Steenerson R, Cronin G. Comparison of the canalith repositioning procedure and vestibular habituation training in forty patients with benign paroxysmal positional vertigo. American Academy of Otolaryngology- Head and Neck Surgery Foundation. 1996; 114: 61-64.
  34. ↑ 34.0 34.1 34.2 Brain and Spine Foundation. Vestibular Rehabilitation Exercises: A Fact Sheet for Patients and Carers. http://www.brainandspine.org.uk/information/publications/brain_and_spine_booklets/vestibular_rehabilitation_exercises/index.html (Accessed October 12 2012).
  35. ↑ Vestibular Rehabilitation Exercises. [Video: Website]. http://www.youtube.com/watch?v=NXyg9n3nFQk. 2011. (Accessed October 30 2012).
  36. ↑ Radke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology. 1999; 53: 1358-1360.
  37. ↑ Brandt-Daroff Exercises for BPPV Dr. Michael Teixido. [Video: Website]. http://www.youtube.com/watch?v=CTZfIv165sY. 2011. (Accessed October 30 2012).
  38. ↑ 38.0 38.1 Nguyen- Huynh, A. T., MD PhD. (2012). Evidence-Based Practice: Management of Vertigo.Otolaryngeol Clin North Am. ,45(5), 925-940. doi:10.1016/j.otc.2012.06.001
  39. ↑ 39.0 39.1 Cohen, H. S., & Sangi-Haghpeykar, H. (2010). Canalith repositioning variations for benign paroxysmal positional vertigo.Otolaryngology - Head and Neck Surgery,143(3), 405-412. doi:10.1016/j.otohns.2010.05.022
  40. ↑ Hain TC, Uddin M., Pharmacological treatment of vertigo.CNS Drugs. 2003;17(2):85-100.
  41. ↑ Maslovara, S. (2014). Importance of accurate diagnosis in benign paroxysmal positional vertigo (BPPV) therapy.Med Glas,11(2).


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