Benign Paroxysmal Positional Vertigo: An Overview


Dinkleberg is a 42-year-old active father of two with an unremarkable past medical history. He reports to your clinic following an appointment with his physician clenching a referral for “Dizziness and Giddiness” (yeah it’s a thing). For a moment, you observe him in the waiting room and notice that he holds his head fairly rigid, almost locked in a straightforward position. When you call him in for his evaluation, his eyes turn to you with almost zero motion occurring at his neck. Somewhat pale, Dinkleberg states that he hasn’t slept very well recently. When you sit him down and ask him why, with a haggard look he utters the following response – “The room spins when I lie down for bed.”

What is BPPV?

Benign Paroxysmal Positional Vertigo (BPPV) is a common vestibular disorder characterized by a short-lived spinning sensation associated with positional changes. It is the most common cause of the signs/symptoms of vertigo (ex. nausea, vomiting, imbalance). The vestibular system, within the inner ear, consists of the otolith organs (the utricle and saccule that detect linear acceleration) and three semicircular canals (anterior, horizontal, posterior canals that detect rotational movement). The otolith organs contain calcium carbonate crystals, aka otoconia, that are normally embedded within a gel-like matrix. When these crystals become dislodged, they can travel into one of the canals - commonly the posterior semicircular canal (due to anatomical orientation) - and interfere with normal fluid mechanics within, sending false signals to the brain, and resulting in the dreaded spinning sensation. 

With a lifetime prevalence of 2.4%, the exact cause of BPPV is unknown - with many cases being idiopathic in nature (50-70% of cases). Others believe that it can also be caused by trauma through either a blow to the head or the consequence of an inner ear pathology. It can theoretically occur to a person of any age, but it usually occurs in the elderly (possibly due to the degenerative changes of age) and rarely in children. Sufferers of this affliction can vary in the way they experience it, with symptoms ranging from mild to severe. One thing is certain - it can have profound quality of life implications (e.g. fearfulness, decreased activity, stiff cervical musculature) for a patient and must be addressed.

How is it evaluated by a Physical Therapist?

BPPV can be evaluated by a physical therapist through administering either the Dix-Hallpike Test (tests the posterior and anterior canals) or Supine Head Roll Test (tests the horizontal canal) which puts the patient through a head and body positional change. Following this positional change, patient response is then observed - vertigo and/or nystagmus (involuntary eye movement) is a positive test. 

*The videos to the right go over both tests >>>

The type of nystagmus observed gives a clinician the most useful information. Here are a few potential observations:

*Note that the presence of a purely unidirectional beating without a torsional component may be indicative of a more centrally-located issue altogether.

How is it treated by a Physical Therapist?

Following a positive test and depending on what the affected canal is, there are many corrective maneuvers that can potentially be administered, all with varying rates of effectiveness and some studies boasting up to a 90% success rate in 1-3 treatments. Listed below are just a few suggestions:

  • For posterior canal involvement, the Epley maneuver and Liberatory/Semont maneuver are popularly performed. 
  • For anterior canal involvement, the Epley and Yacovino (deep head hanging) maneuvers. 
  • For horizontal canal involvement, many more options - including the BBQ roll, Appiani, Gufoni, and Vannuchi maneuvers.

The videos below provide some instruction on how the Epley, Liberatory/Semont, Yacovino/Deep Head Hanging, and BBQ maneuvers are performed:

***An important note on interpretationWhile the presence of short-lived upbeating nystagmus (indicating the posterior canal) is often the most common result and offers a relatively simple course of action, things can get a little dicey when multiple canals are involved, otoconia are adhered to the cupula of a canal (aka cupulolithiasis), or the issue is more of a centrally-located problem.

By NO means should a clinician base their decision-making off of just this article. Multiple resources, including additional scientific research and attendance of CEU courses, should be utilized to further one's understanding and treatment of BPPV.

If you believe you are exhibiting signs/symptoms consistent with BPPV, it is strongly advised to seek out a qualified professional for appropriate evaluation and treatment of your condition.

Further Reading

The following research articles were found to be useful and are recommended for further reading:

One final thought. Many people claim that they have vertigo when they actually do not. This usually comes from a misunderstanding of what vertigo actually is. Appropriate steps should be taken to tease out the difference and education provided. The graphic below may be useful for differentiation:

  a person may claim that they have vertigo when they are actually experiencing something else - appropriate steps should be taken to tease out the difference and educate accordingly.