what is BPPV?
BPPV stands for Benign Paroxysmal Positional Vertigo and is a condition where tiny little calcium carbonate crystals within your vestibular system become dislodged from the vestibular organ into the canals.
Guess what? Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common causes of dizziness! There are 3 different canals within each inner ear (6 total). Those little ear crystals get displaced most often in the posterior canals, less often in the horizontal canals (although a new study suggests it happens almost in 50% of cases!) and possibly not at all in the anterior canals.
This is the condition EVERYONE talks about, and for good reason, because it is the most common cause, but also because people experience the quickest relief from it with repositioning maneuvers as well!
You may have heard something like:
“One moment the room was spinning, this crazy guy put me in these different positions, and all the sudden it’s gone!”
It’s great when BPPV can be resolved so quickly and most of the time it is, but there are times where it’s not so clear where the crystals are, or times when BPPV isn’t resolved with the typical repositioning maneuvers. That’s where it can get frustrating, not only for the patient, but also for whoever is treating it. We call those cases atypical BPPV or chronic BPPV. If this is you, don’t give up! You may just need to find the right repositioning maneuver for you, or you may need to consider other conditions that might be causing your symptoms.
How do you test for BPPV?
To test for BPPV, you use the dix hallpike or roll test. I know, sounds like something risk-ay, but it’s just what the name of the head position is! The intent of these tests is to cause the crystals in the inner ear to move. So yes, to test for it, we do have to trigger your symptoms. While this literally and figuratively may be triggering for you, especially if you have anxiety with vertigo, the good news is that if you test positive, we can most likely fix the problem in a couple of minutes! With the dix hallpike test, your head is rotated 45 degrees to one side, then you lay down with your head extended about 20 degrees. I have a YouTube video here that goes through how to test for BPPV! This will provoke symptoms as well as nystagmus (a rhythmic motion of the eyes). The direction of the nystagmus will tell the vestibular specialist which canal the crystals are displaced in. If you’ve got a stiff neck, sometimes we have to get creative with how to position you to get those crystals to move.
What does BPPV feel like?
People often describe vertigo from BPPV as a “room spinning sensation”, but everyone can interpret dizziness differently. I’m often not surprised when people give a variety of descriptions on what they feel. Frequently people will describe the sensation as a wave, feeling like they are being pushed over or falling, feeling off balance, or just a feeling of lightheadedness.
How do I know if I have BPPV?
If you are experiencing dizziness, there is a high likelihood that it is BPPV if:
You are getting dizziness with positional changes such as laying down, rolling over, or looking up.
Your dizziness only lasts for seconds or up to a minute.
Your dizziness is described as a spinning sensation (again, the description of dizziness can vary from person to person).
Will BPPV go away on it’s own?
BPPV may spontaneously resolve, the crystals can move around the canal with your normal daily movements and end up repositioning back to where they are supposed to be. However, there is no guarantee that it will, you could be waiting days, weeks, or months for BPPV to resolve on its own. Who wants to be waiting for something that could be fixed right away? During that time you are at risk for falling during vertigo episodes and developing more chronic conditions with how the brain is receiving abnormal information from the vestibular system. Not to mention that the longer you have BPPV, the higher chance you have of developing it again. I suggest getting rid of it as soon as you can! If you need help with this check out my vertigo kickstart course below!
How is BPPV treated?
BPPV is treated with the canalith repositioning maneuver. This maneuver is typically a series of 3 positions to move those crystals around the canal and back where they are supposed to reside.
In the case of L posterior canalithisis, the head is rotated 45 degrees to the L, then the patient lays down with their head extended about 20 degrees. The head is then rotated 45 degrees to the right after symptoms stop, then the patient lays on their R side and looks at an angle down toward the floor before sitting up.
Depending on which canal the crystals are displaced in, there is a different maneuver for each. There are also different maneuvers depending on if the crystals are floating in the canal (canalithiasis), or if they are stuck to the cupula at the end of the canal (cupulothiasis).
If your dizziness is lasting less than a minute and coming on with the dix hallpike test you learned in the video above, then check out this video to learn how to do the modified epley maneuver to reposition those crystals. The basic steps to repositioning with this maneuver are
turn your head 45 degrees to the involved side and lay down with head in 20 degrees extension (wait duration of symptoms + 30 seconds).
rotate your head 45 degrees to the opposite direction while maintaining the 20 degrees of extension and wait the same amount of time as step 1
lay onto your uninvolved side and tuck your chin to your shoulder (wait the same amount of time in this position as position 1)
sit up with your chin tucked
Are there different types of BPPV?
BPPV can either be from crystals that are floating in the canal (canalithiasis), or if they are stuck to the cupula at the end of the canal (cupulothiasis). If the crystals are stuck to the cupula, they often need a quick maneuver to knock them off (this may completely resolve it) before they are then guided around the canal (canalithiasis).
What are the risk factors for BPPV?
While head trauma (whiplash, fall, concussion, brain injury) is noted as one of the most common reasons for BPPV, there are many co-morbidities that are linked to a higher risk of developing BPPV such as:
Age: more common over 50 years old
Gender: more common in females
Meniere’s disease
Osteoporosis and osteopenia
Vitamin D deficiency
High cholesterol
Migraine
Cervical arthritis
Sleep disorders
What are the long term effects of BPPV?
BPPV can have a profound effect on work, quality of life, and be a significant contributor to falls. It is estimated that it takes months, and costs about $2,000 to arrive at a diagnosis of BPPV (2). This is not only a significant waste of money and resources, but also of time. With vestibular physical therapy we can diagnose, treat, and resolve BPPV in 90% of cases (1), typically within 1 visit.
BPPV can not only cause dizziness, but also disrupt how the brain processes information coming from the inner ear for balance. Imbalance is less prevalent with BPPV when compared to a vestibular hypofunction, but can still be a factor. When the brain gets abnormal information from the inner ear (such as when BPPV is present), it prioritizes other sensory systems for balance and stability. This is good in the short term but can be detrimental to recovery. It is important to test and address balance impairments, especially after BPPV to re-integrate appropriate sensory processing in the brain.
How can I prevent recurrence of BPPV?
Vestibular rehab after treatment for BPPV may decrease re-occurrence (3)!
It is also important to manage any of the co-morbidities listed above that are risk factors for BPPV.
Exercise regularly! Shoot for 30 min a day.
Stay hydrated.
Don’t avoid movements in fear of causing BPPV, this may put you at higher risk for BPPV returning.
Get treated for BPPV as soon as it comes on, waiting longer than 24 hours will put you at a higher risk of it reoccuring (4).
Learn more in my video here.
Why would moving more help decrease risk of BPPV?
The theory is that moving more and participating in vestibular rehab helps disperse the otoconia (tiny ear crystals) to sit more uniformly on that sticky surface inside the otolith organ. Limiting your movement may contribute to them clumping together and have a higher likelihood of getting displaced.
Getting your heart rate up with cardiovascular exercise is going to help improve blood flow to the brain, helping to promote the health of the inner ear and brain.
Staying hydrated will perhaps maintain the “stickiness” of the surface that those otoconia sit on, preventing them from getting displaced.
Who should I see for BPPV?
Make sure you see a vestibular physical therapist if you are having dizziness with positional changes, and have them address any balance impairments! Often physicians or MD’s may assess for BPPV but not be comfortable treating, while vestibular physical therapists can assess and treat BPPV within the first visit, resolving your symptoms sooner! If you would like help with fixing BPPV, check out my vertigo kickstart course below!
