Physical Therapy Haven

Population Characteristics:1

• Prevalence: Lifetime prevalence of 2.4%, 1 year prevalence of 1.6%
  • Lifetime prevalence of 3.2% in females and 1.6% in males
  • 1 year prevalence rates of those 60 years and older are almost 7x higher than those 18-39 years of age
• Incidence: .6%
• Average age of onset of 49 years 
• BPPV is responsible for 8% of moderate to severe cases of dizziness and vertigo
• Roughly 50% of dizziness in the elderly population is due to BPPV

Pathophysiology:2,3,4

• BPPV is caused by displacement of the otoconia from the utriclar membrane, causing an alteration in the hemodynamics of the inner ear. Consequently, the fluid within the inner ear lags behind movements of the head, which leads to vertigo and nystagmus. There are two forms of BPPV:
  • Canalithiasis: The otoconia are displaced into the one of the three semicircular canals (anterior, posterior, or horizontal) which causes vertigo and nystagmus of short onset and short duration (less than 60 seconds)
  • Cupulothiasis: The otoconia are displaced and attach onto the cupula, which causes vertigo and nystagmus of longer than 60 seconds
• Causes for BPPV include:
  • Trauma to the head
  • Meniere's Disease
  • Aging
  • Labyrinthitis

Signs and Symptoms:4

Signs and symptoms of BPPV are often induced by changes in head position and include:

• Dizziness
• Nausea and vomiting
• Vertigo
• Nystagmus
• Lightheadedness 
• Loss of balance

Diagnosis:5

• BPPV is fairly straight-forwards in regards to diagnosis and requires taking a comprehensive patient history followed by a physical examination 
• Posterior canal BPPV:
  • Accounts for 90% of BPPV cases
  • The Dix-Hallpike manuever is known as the golden standard to diagnose posterior canal BPPV: https://www.youtube.com/watch?v=vRpwf2mI3SU
• Horizontal canal BPPV:
  • Accounts for 5-15% of BPPV cases
  • The supine log roll test is used to diagnose horizontal canal BPPV: https://www.youtube.com/watch?v=Tjpcua7hGHs
• Anterior canal BPPV:
  • Accounts for 1-2% of BPPV cases
  • The Dix-Hallpike maneuver is used to diagnose contralateral anterior canal BPPV and is much more difficult to diagnose in comparison to posterior and horizontal canal testing

Prognosis:6

• The symptoms of BPPV usually self-resolve within two months with no treatment
• There is an 80% success rate of treatment maneuvers after the first treatment session
  • After 2-3 sessions, this percentage grows to 95% success
• Roughly 33% of BPPV patients have a recurrence within the first year. After 5 years, the recurrence rate is about 50%. 

Physical Therapy Interventions:6,7

• Epley or Semont manuever for treating posterior canal BPPV
  • Epley: https://www.youtube.com/watch?v=ZqokxZRbJfw
  • Semont: https://www.youtube.com/watch?v=A72UjulJSzE
• BBQ roll method for treating horizontal canal BPPV
  • https://www.youtube.com/watch?v=x2v-Ojrx7qc
• Gaze stabilization exercises (x1 and x2) for habituation
• Dynamic balance/gait exercises with emphasis on head turns as BPPV symptoms are resolving 

1. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78(7): 710.

2. Oas JG. Benign paroxysmal positional vertigo: a clinican's perspective. ANn N Y Acad Sci. 2001;942: 201-209. 

3. AW AT, Todd MJ, Aw GE, et al. A study of its three-dimensional spatio-temporal characteristics. Neurology. 2005;64(11): 1897-1905.

4. Musat G. The clinical characteristics and treatment of benign paroxysmal positional vertigo in the elderly. Romanian Journal of Neurology. 2010;9(4): 189-192. 

5. Balatsouras DG, Koukoutsis G, Ganelis P, et al. Diagnosis of single- or multiple-canal benign paroxysmal positional vertigo according to the type of nystagmus. International Journal of Otolaryngology. 2011;2011: 1-13. 

6. Hain, TC. Benign paroxysmal positional vertigo. Chicago Dizziness and Hearing Web site. March 2, 2014. Available at: http://www.dizziness-and-balance.com/disorders/bppv/bppv.html. Accessed April 30, 2014. 

7. Helminski JO, Zee DS, Janssen I, and Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Physical Therapy. 2010;90(5): 663-678.