Diagnosis and treatment Strategies for BPPV

Positional SCC Direction of nystagmus Type of BPPV Side of involvement

test Involvement (Duration)
Dix- Posterior SCC Up-beating torsional to side Canalithiasis Direction of torsional
Hallpike of head rotation < 1 minute nystagmus usually
Test the Side of head rotation
Anterior SCC± Down-beating torsional to Cupulolithiasis
side of head rotation* > 1 minute

Supine Roll Lateral SCC Horizontal nystagmus

Test Geotropic
(toward the ground) Canalithiasis More intense Side**
<1 minute
Apogeotropic Cupulolithiasis Less intense Side**
(away from the ground) > 1 minute

* Alignment of Anterior SCC may not provoke all nystagmus components in Dix Hallpike
* * Side cannot be interpreted in between 11.5 % and 16% in individuals with LC BPPV using the SRT alone (Lee et al, 2007, Lee et al, 2010,
Choung et al, 2007)
±Anterior canal BPPV is very uncommon, If you are seeing Down beating nystagmus there are atypical PC presentations (Helminski, 2019;
2022) and it could be a central problem. You might want to seek help form a more experienced vestibular physical therapist.

Differential diagnosis of semicircular canal (SCC) involvement, type of BPPV, and side of involvement

Permission to reproduce with citation of creator: Anne K. Galgon PT PhD NCS.

Diagnosis and treatment Strategies for BPPV

Form of LC BPPV Positional test Direction of horizontal nystagmus

Geotropic Spontaneous (pseudo) nystagmus Away from side of involvement

(Canalithiasis)
Bow & Lean (head pitch/bending) Away from side of involvement
Up pitch (Lean) Toward the side of involvement
Down pitch (Bow)
Sit to Supine Test Away for side of involvement

Apogeotropic Spontaneous (pseudo) nystagmus Toward the side of involvement

(Cupulolithiasis)
Bow & Lean (head pitch/bending) Toward the side of involvement
Up pitch (Lean) Away from the side of involvement
(or Pitch) Test Down pitch (Bow)
Sit to Supine Test Toward the side of involvement
Supine Null Point No nystagmus
Rotated to side of involvement
Summary of additional tests to determine side of involvement for Lateral (horizontal) BPPV
Any of these finding may be seen in an individual with LC BPPV, but typically not all (Califona et al, 2010; Riga et al 2014).

Permission to reproduce with citation of creator: Anne K. Galgon PT PhD NCS.

Diagnosis and treatment Strategies for BPPV

Canal and type Maneuver Option 1 Maneuver option 2 Maneuver Option 3

Posterior Canal CA CRT (AKA Epley)*** Liberatory (AKA Semont) Brandt Daroff

Anterior Canal CA CRT (AKA Epley) Reverse CRT or Anterior CRT Liberatory/Brandt
Straight (Deep) head hanging Daroff
Posterior Canal CU Liberatory (AKA Semont) Brandt Daroff

Anterior Canal CU Liberatory (AKA Semont) Liberatory with head down. Brandt Daroff

Lateral canal Log Roll or BBQ roll (AKA Contra sidelying head rotation Force prolonged
Geotropic or CAp Lempert) down (AKA Gufoni or Appiani) positioning

Lateral Canal Modified log Roll with Ipsi sidelying head rotation up Head shaking
Apogeotropic or CU Vibration (AKA Kim) (CUc or CAa) Forced prolonged
CAa Ipsi sidelying head rotation down position
CUc (?) Vannucchi–
CUs Contra sidelying head rotation Asprella LM
down (CUu)
(AKA mod Gufoni, Casani)
CU=Cupulolithiasis, CUu =Utricular Side, CUc= Canal Side; CA: Canalithiasis, CAa: Anterior Arm, CAp: Posterior Arm

Permission to reproduce with citation of creator: Anne K. Galgon PT PhD NCS.