REHABILITATION FOR BENIGN

PAROXYSMAL POSITIONAL VERTIGO

By: Jesus A. Garcia

 WHAT IS BPPV?

• Benign Paroxysmal Positional Vertigo (BPPV) is a mechanical disorder of the peripheral

vestibular system, characterized by repeated brief (less than 1 minute) episodes of positional
vertigo caused by crystals of calcium carbonate (otoconia) which are dislodged from the utricle
and travel into the semicircular canals (canalithasis), or less commonly, adhering to the cupula
and rendering it sensitive to gravity (cupulolithasis).
• BPPV stands for:
• Benign: of no danger to health
• Paroxysmal: happening in sudden, brief spells
• Positional: triggered by particular head movements or positions
• Vertigo: an internal sense of irregular or whirling motion either of yourself or of objects around
you
• Posterior/Inferior canal BPPV (PC BPPV): the most common canal affected, accounting for 80 to
90% of cases
• Horizontal/Lateral canal BPPV (HC BPPV): accounts for 5 to 15% of cases
• Anterior/Superior canal BPPV (AC BPPV): the least common, accounts for 1 to 2% of cases
 DIAGNOSIS

• Diagnosis of this condition is based on the characteristics of nystagmus elicited by

performing the Dix-Hallpike maneuver/procedure, or Supine roll test (SRT) which
elicits characteristic nystagmus that follows head movement in the plane of the involved
semicircular canal, with features of latency and fatigability.
• Dix-Hallpike maneuver: The patient sits on the examination table and the clinician turns
the head horizontally 45°. As the examiner maintains the 45° rotation, the patient is
quickly brought to a supine position with the neck extended 30° beyond the horizontal.
The examiner must look for nystagmus and ask the patient if vertigo is being
experienced. The patient is then slowly brought back to the starting position, and the
other side is tested. The side that reproduces nystagmus and vertigo is the side that has
the benign paroxysmal positional vertigo. (For Posterior and Anterior Canal)
• Supine roll test: The patient is brought from sitting to a supine position, with the head
turned 90° to one side and flexed about 20° forward. Once supine, the eyes are typically
observed for about 30 seconds, a pillow can be used to maintain head flexion. The head
is the rotated to midline for 30 seconds, and then 90 degrees to the other side. (For
Horizontal/Lateral Canal)
• Repeated clinical testing for BPPV within the same session is important to avoid a false
negative DHP or SRT.
 • The cumulative lifetime incidence is approximately
WHAT POPULATION 10% at 80 years, with the peak incidence of BPPV
DOES BPPV AFFECT? between 50 and 70 years of age and a predilection
towards women at 2.2:1 when compared to men.
 • Dizziness
• A sense that you or your surroundings are spinning or moving (vertigo)
• A loss of balance or unsteadiness
• Nausea
• Vomiting

SIGNS & • Involuntary movements of your eyes from side to side

• Inability to control your eye movements
SYMPTOMS & • (Signs and symptoms of BPPV can come and go and commonly last less than
one minute)
CAUSES • Often there is no known cause for BPPV, this is called idiopathic BPPV
• When there is a known cause, BPPV is often associated with a minor to severe
blow to the head
• Less common causes include disorders that damage the inner ear or, rarely,
damage that occurs during ear surgery or keeping the head in the same
position for a long time, such as in the dentist chair, at the beauty salon or
during strict bed rest
 • Canalith Repositioning Procedures (Epley maneuver,
Semont-Liberatory maneuver, BBQ roll, Appiani
maneuver)
• Vestibular suppressants (such as antihistamines,
R E H A B I L I TAT I O N sedatives, or scopolamine) may be tried if symptoms
are severe.
• Antiemetic medicines may also be used to reduce
nausea and vomiting that can occur with vertigo.
• Surgery may be used to treat BPPV in rare cases
 R E H A B I L I TAT I O N

•BPPV is typically responsive to Canalith Repositioning

Procedures (CRP).The most common and most preferred
form of CRP is the Epley maneuver. Followed by the
Semont-Liberatory maneuver when the Epley maneuver is
unsuccessful, for PC BPPV. For HC BPPV the BBQ roll and
the Appiani maneuver are performed.
•Epley maneuver: Start by having the patient in long sitting
on the bed, turn the head 45° to the affected side and have
the patient lie down while keeping the head turned and wait
for 30 seconds. Then turn the head to the opposite side until
it is 45° and wait 30 seconds and then roll over onto the side
in a side lying position so that the patient is looking at the
floor and then sit up.
•Semont-Liberatory maneuver: The patient is seated at the
edge of the bed and the head is looking away from the side
that causes vertigo. The clinician then lowers the patient
quickly to the side that is causing vertigo so that the patient
is looking toward the ceiling and wait for 30 seconds. The
clinician then quickly moves the patient to the other side of
the table so that the patient is looking down at the table and
wait for 30 seconds. The clinician then helps the patient up
into sitting.
 R E H A B I L ATAT I O N

• BBQ roll: Patient lies in side lying and waits 30

seconds, then rolls onto their back and waits another
30 seconds. The patient then rolls to the opposite
side and waits 30 seconds, the patient then tucks
their chin down slightly and rolls onto their stomach
while propping themselves up on their elbows and
wait 30 seconds. They then roll onto the initial side
lying position and wait 30 seconds and finally
slowly return to sitting.
• Appiani maneuver: The patient is to lay away from
the affected side, you’ll want to keep the patient’s
head straight for one to two minutes or until any
nystagmus fatigues. Once in the side lying position
you want to turn their head facing the floor, for one
to two minutes or until nystagmus fatigues. Finally
the patient is returned to the seated position and
turn their head back to the center.
• The treatment of positional vertigo has been
demonstrated to reduce the incidence of falls by
64%
• Although BPPV may resolve spontaneously,
without treatment, up to 50% of cases may take
longer than three months to resolve, hence the CRP
is the preferred treatment option.

R E H AB I L I TAT I O N C O N T.
(EVIDENCE)
• In an article by Laura Power, Katherine Murray and David J.
Szmulewicz titled “Characteristics of assessment and treatment
in Benign Paroxymsal Positional Vertigo (BPPV).” they
designed an observational study with 314 patients with various
forms of BPPV and were treated with Canalith repositioning
maneuvers/procedure (CRP) for posterior canal (PC) or
horizontal canal (HC) BPPV.
• In 91% of cases, PC BPPV was effectively treated in 2
maneuvers or less.
• The Epley maneuver EM was selected as the CRP in 98% (246)
of PC BPPV presentations.
• Similarly 88% of HC BPPV presentations were effectively
managed with 2 treatments
• The BBQ roll was performed 41% (19) of patients, and in 25%
of patients (21) the Appiani maneuver.
• There were four instances (4/19, 21%) in which the BBQ roll
failed to clear the otoconia, and the Appiani maneuver was
performed resolving the BPPV.
• Patients were treated with a maximum of 3 maneuvers within 1
session, or until a negative DHP or SRT was obtained, unless
contraindicated.
 EPLEY MANEUVER VIDEO

• https://youtu.be/lbPbM8018CE
 • O'Sullivan SB, Schmitz TJ, Fulk GD, O'Sullivan SB.
Physical Rehabilitation. Philadelphia: F.A. Davis;
2019.
• Power L, Murray K, Szmulewicz DJ. Characteristics
of assessment and treatment in Benign Paroxysmal
REFERENCES Positional Vertigo (BPPV). Journal of Vestibular
Research. 2020;30(1):55-62. doi:10.3233/ves-
190687.
• Roy SH, Wolf SL, Scalzitti DA. The Rehabilitation
Specialist's Handbook. Philadelphia: F.A. Davis;
2013.