BPPV - Physical Diagnosis and Management

Anwesh Pradhan, MPT
(Neurological & Psychosomatic Disorders)
Assistant Professor, Nopany Institute of Healthcare Studies, Kolkata
Benign Paroxysmal Positional
Vertigo
NIHS, Kol:Mobility P&R,MDN:IAP-WB,2015

Vertigo
 Vertigo is the illusion of movement of the self or the
environment
Causes:
 Due to mechanical problems of the inner ear (e.g.,
BPPV)
 Due to lesions that cause loss of function of vestibular
pathways on one side (e.g., vestibular neuritis)
 Sudden imbalance of tonic neural activity in the
vestibulocortical pathway (labyrinth–VIIIth nerve–
vestibular nucleus–vestibular thalamus–vestibular
cortex)

Vertigo (BPPV)
 BPPV is the most common cause of vertigo
 BPPV was first described by Barany (1921)
 Problem of inner ear

Benign Paroxysmal Positional Vertigo
(BPPV)
 Typically, a patient with BPPV will complain of brief
episodes of vertigo precipitated by rapid change of
head positions or postures.
 Sometimes symptoms are brought about by assuming
very specific head positions like-
Head positions involve rapid extension of the neck,
often with the head turned to one side (as when
looking up to a high shelf or backing a car out of a
garage)
Lateral head tilts toward the affected ear.

Benign Paroxysmal Positional Vertigo
(BPPV)
 The symptoms often appear when a patient rolls
from side to side in bed.
 Patients can usually identify the offending head
position, which they often studiously avoid.
 Many patients also complain of mild postural
instability between attacks.

Vertigo (BPPV)
 The vertigo lasts only 30 seconds to 2 minutes (usually
less than 1 minute) and disappears even if the
precipitating position is maintained.
 Hearing loss, aural fullness, and tinnitus are not seen in
this condition, which most commonly occurs
spontaneously in the elderly population but can be
seen in any age group after even mild head trauma.

Vertigo (BPPV)
 Women are more commonly affected than men.
 Bilateral involvement can be found in 10% of the
spontaneous cases and 20% of the traumatic cases.
 Spontaneous remissions are common, but recurrences
can occur, and the condition may trouble the patient
intermittently for years.

Cupulolithiasis Theory
 Described by Schuknecht (1969)- found basophilic
deposits on the cupula of the posterior canal of BPPV
patients
 In cupulolithiasis, the debris (probably fragments of
otoconia- calcium carbonate crystals, from the utricle)
adhere to the cupula of the semicircular canals making the
ampulla gravity sensitive
 With movement into the head hanging position, gravity
displaces the weighted cupula, resulting in an abnormal
signal from that canal - Vertigo

Canalithiasis Theory
 Proposed by Hall, Ruby and McClure (1979)- debris is
not adherent to cupula
 The debris (calcium carbonate crystals) will float freely in
the endolymph in the long arm of the Semicircular canals
 When the head is moved into the head-hanging position,
the debris moves to the most dependent portion of the
canal
 The movement of the debris causes the endolymph to
move, in turn overcoming the inertia of the cupula, and an
abnormal signal is sent to the central nervous system-
Vertigo

DIAGNOSTIC TEST

Dix-Hallpike test [anterior or posterior canal
benign paroxysmal positional vertigo]
1. The patient sits on the bed or examination table, and the head is
turned
2. 45 degrees horizontally toward the labyrinth to be tested
(position 1).
3. The examiner quickly brings the head and trunk straight back
“en bloc,” so that the head is hanging over the edge of the
examination table by 20 to 30 degrees (position 2).
4. The examiner asks whether the patient has vertigo and observes
for nystagmus.
5. The patient’s upper body is then brought up slowly to a sitting
position with the head still turned 45 degrees, and nystagmus is
sought again.
6. This test then is repeated with the head turned 45 degrees in the
other direction.

• The figure below also shows the right labyrinth with
free-floating otoconia in the right posterior
semicircular canals (large black arrows). During the
Hallpike- Dix test, this debris would move, resulting in
nystagmus andvertigo when the test is performed to
the right side but notwhen the test is performed to the
left side. (Modified fromTusa and Herdman, 1998.4)

Side-lying test [for anterior or posterior canal
benign paroxysmal positional vertigo]
1. The patient sits on the bed or examination table with the legs
over the side, and the head is rotated 45 degrees horizontally
away from the labyrinth to be tested (position 1).
2. The examiner then quickly brings the patient’s head and trunk
down on the side opposite to the direction the head is turned
(position 2).
3. The patient is asked to report any vertigo and is observed for
nystagmus.
4. The patient is then brought to a sitting position with the head still
turned 45 degrees, and the examiner rechecks for nystagmus and
vertigo.
5. The test is repeated with head turned 45 degrees horizontally to
the other side.

 During the Side-lying test, the debris would move,
resulting in nystagmus and vertigo when the test is
performed to the affected side but not when it is is
performed to the unaffected side.
 This test is also useful for anterior canal BPPV,
because debris in this canal would move when the test
is done on the affected side. (Modified from Tusa and
Herdman, 1998.4)

Roll test [for horizontal canal benign paroxysmal
positional vertigo]
1. The patient is laid supine with the head flexed 20 degrees.
2. The head is quickly rolled to one side, nystagmus is looked
for and the patient is asked to report any vertigo.
3. The head is then slowly rolled back to a supine position.
4. The head is then quickly rolled to the other side,
nystagmus is looked for, and the patient is asked to report
any vertigo. (Modified from Tusa and Herdman, 1998.4)

Test Series [vertigo when lying on the right
side]
 The series is as follows:
1. Perform the Dix-Hallpike test on the left side.
2. Perform the Dix-Hallpike test on the right side.
3. If the patient has no vertigo: Before sitting the patient
up from the right side, perform a roll test by having the
patient turn the head quickly to the left.
4. After 30 seconds, have the patient quickly turn the
head back to the right.
5. After 30 seconds, have the patient sit up.

TREATMENT

Treatment of BPPV
 Canalithiasis: The Canalith Repositioning
Procedure- Modified by Epley
 Cupulolithiasis: The Liberatory Maneuver-Modified
by Semonts
 Bar-B-Que roll or Canalith repositioning treatment
for horizontal SCC BPPV
 Brandt-Daroff Habituation Exercises

Procedure of Epley’s Canalith Repositioning
Maneuver (Posterior SSC)
1. Patient is made to sit in the treatment table comfortably.
2. Starting position is sitting on the treatment table with
patient’s head turned 45º to the affected side.
3. A pillow is placed behind the patient so that on lying
back it will be under patient’s shoulder.
4. The patient is made to lie back quickly with shoulders on
the pillow, neck extended, and head resting on the edge of
the treatment table. In this position, the affected ear is
underneath. This position is maintained for 3 min.
5. Then the patient’s head is turned 90º to the opposite side
(without raising it) and the body rolled such that the
shoulders are aligned perpendicularly to the floor
(affected ear up) and maintained again for 4 min.

6. Patient’s body and head is turned another 90º towards the
opposite side i.e. the nose points 30º below the plane of the
treatment table and maintained for another 4 mins.
7. Then sit up on the treatment table upright quickly.
8. Then the patient is asked to maintain this position of head
for 48 hours and avoid provoking position for one week.
Idea is based on that the debris is free-floating in the
posterior canal, and the position changes are designed
to move the debris out of the posterior canal and into
common crus

Patient is treated with Epley’s canalith repositioning maneuver.
Diagrammatic representation of the movement of the loose otoconia inside the
posterior semicircular canal during Epley’s canalith repositioning maneuver.

Canalith Repositioning Treatment
for Anterior SCC BPPV
 Anterior SCC BPPV is treated the same way as
posterior SCC BPPV. The difficulty lies in deciding
which side to treat. The best way to decide is based on
the direction of the nystagmus rather than on the side
of the dependent labyrinth (ear) during the Dix-
Hallpike test.

Procedure of Semont’s Liberatory
Maneuver (Posterior SCC)
1. Patient is made to sit in the treatment table
comfortably.
2. Therapist will hold the head of the patient with both
hands.
3. Then the patient is swinged to the affected side
quickly with the head hanging down. If nystagmus
comes or patient speak about the vertigo then
maintain the position for 2-3 mins, if no nystagmus
comes or the patient does not speak about the vertigo
then turn the head in 45º face up, nystagmus or
vertigo will come now and then maintain the same
position for 2-3 mins

4. Therapist has to hold the patient’s head and neck with
both hands and swing the patient quickly to the
opposite side. The speed of the head must be 0 at the
moment it touches the treatment table. These position
is maintained for 5 mins. Then quickly the patient is
brought to sitting position. And then the patient is
asked to maintain this upright position of head for 48
hours and avoid provoking position for 1 week.
The approach works by floating the debris through
the canal system to the common crus

Patient is treated with Semont’s liberatory maneuver
Diagrammatic representation of various position of the patient in
Semont’s liberatory maneuver.NIHS, Kol:Mobility P&R,MDN:IAP-WB,2015

Liberatory Maneuver (Semont or
Brisk Treatment) for Anterior SCC BPPV
 For anterior SCC BPPV, the procedure must be modified in
order to move the head in the plane of the anterior SCC.
For sake of discussion, assume that the patient has debris in
the right anterior SCC. The procedure is as follows:
1. The patient sits on the examination table sideways, but the
head is rotated 45 degrees toward the right side.
2. The patient is then moved rapidly onto the right side
(parallel to the plane of the affected anterior SCC).
3. After 1 minute, the patient is rapidly moved through the
initial sitting position to the left side with the head still
positioned 45 degrees toward the right side (nose is now
angled 45 degrees up toward the ceiling).
4. The patient holds this position for 1 minute and then moves
slowly to a sitting position.

Bar-B-Que roll or Canalith repositioning
treatment for horizontal SCC BPPV
 To dislodge otoconia attached to the cupula of the
horizontal SCC (cupulolithiasis) and treatment of
horizontal SCC canalithiasis
1. The patient’s head slowly rolls away from the affected ear
until the face is pointed up; this position is held for about
15 seconds, or until the dizziness stops.
2. The patient continues to roll the head in the same direction
until the affected ear is up; this position is held for about 15
seconds, or until the dizziness stops.
3. The patient rolls the head and body in the same direction
until the face is down.
4. After 15 seconds, the patient slowly sits up, keeping the
head level or pitched down 30 degrees.

 These two variations of the CRT for horizontal SCC
BPPV are referred to as the 270-degree roll and the
360- degree roll, respectively
 Patients can be taught to perform this treatment at
home. Patients repeat this treatment once each morning
until they experience no symptoms during the
treatment

Brandt-Daroff treatment [for treatment of
posterior semicircular canal benign paroxysmal positional vertigo]
 The patient is moved quickly into the side-lying
position on the affected side and stays in that position
until 30 seconds after the vertigo has stopped.
 The patient then sits up and again waits for the vertigo
to stop. The patient then repeats the movement to the
opposite side, stays there for 30 seconds after vertigo
stops, and sits up.
 The entire treatment is repeated 10 to 20 times, three
times a day, until the patient has no vertigo for 2 days
in a row. AC anterior canal; PC posterior canal. Black
arrows indicate position and movement of debris.
(Modified from Tusa and Herdman, 1998.4)

Brandt-Daroff Habituation Exercises
for Anterior SCC BPPV
 Brandt-Daroff exercises can be used to treat anterior
SCC BPPV, because the head is moved in the plane of
the posterior SCC on one side and of the anterior SCC
on the other side.

Other Habituation exercises
 Tangeman & Wheeler: 3 Phases
 Phase I: similar to Brandt & Daroff protocal and
consist of having the patient move repeatedly to
Hallpike-Dix position
 Phase II & III: Wide varity of balance exercises that
that incorporate eye and head movt. – similar to
Sawthorne-Cooksey exercise for vestibular
hypofunction.

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eMedicine Specialties : Otolaryngology and Facial Plastic Surgery :Vertigo
And Dizziness : November 25, 2004

Doubt?
anwesh9_pt@yahoo.co.in
+91 9932874589
+91 9775321090

THANK YOU

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