Benign Positional Paroxysmal Vertigo (BPPV) refers to a common condition experienced by a significant amount of people across the lifespan that presents as dizziness or vertigo (feeling that the environment or the individual is spinning). Most commonly this occurs between the ages of 50-70 and affects women more frequently than men.
The semicircular canals are a series of what are essentially tubes that exist in pairs on either side of our skull. We have one oriented towards the front, the side, and back of our skull that provide information to the brain on the position and movement of our head through space. Each canal is paired to the opposite one on the other side of our head and they are a highly coordinated system that can detect very small changes in position and posture. Inside the canal are specialized sensory cells and nervous system tissue that reside within the fluid-filled canal. The fluid inside the canal is slightly heavier than water and will slosh back and forth depending on how the head is positioned and how it moves. The pressure change from the fluid moving will stimulate the cells in the canal and produce an electrical signal that our brain can interpret as movement. It is important that both sets of canals provide the brain with the same information and at the same time to avoid confusion.
BPPV is thought to occur when a small crystal (otoconia) or clump of cellular debris (the body’s own tissues) ends up in a part of our semicircular canals where it does not belong. The otoconia are typically stored in small organs called the utricle/saccule that reside in our inner ear. These organs attach to the ends of our semicircular canals and it is possible for small objects to pass between these areas. The crystals that normally reside inside our ear organs are used by our body to send information about gravity or the movement of our body through space in very specific directions to our brain. They are denser and heavier than the surrounding tissues which allows them to tell the brain what is changing between the relationship of our body and the environment. The current hypothesis is that these crystals can sometimes be dislodged and inappropriately move into the semicircular canals. There is some evidence to suggest that a clump of cells from our own body can sometimes form an object big enough and dense enough to create the same effect.
BPPV is thought to occur when a small crystal (otoconia) or clump of cellular debris (the body’s own tissues) ends up in a part of our semicircular canals where it does not belong. The otoconia are typically stored in small organs called the utricle/saccule that reside in our inner ear. These organs attach to the ends of our semicircular canals and it is possible for small objects to pass between these areas. The crystals that normally reside inside our ear organs are used by our body to send information about gravity or the movement of our body through space in very specific directions to our brain. They are denser and heavier than the surrounding tissues which allows them to tell the brain what is changing between the relationship of our body and the environment. The current hypothesis is that these crystals can sometimes be dislodged and inappropriately move into the semicircular canals. There is some evidence to suggest that a clump of cells from our own body can sometimes form an object big enough and dense enough to create the same effect.
A typical presentation will be of an individual who reports episodes of dizziness or the sensation that the room is spinning (vertigo) when they position themselves or their head in a certain way. It may be that it is always when they roll over in bed, or always when they look up at a particular cupboard in their kitchen. The vertigo will sometimes last for only a minute or two, but in rare cases will continue until the position is changed. People will usually interpret this as a feeling that the room is spinning and can be associated with nausea, headache, and pain in the neck and upper shoulders. Many people will learn how to avoid symptom creating positions and some can go days at a time without an episode if they restrict their activity and movement. However, avoiding symptoms can promote stiffness of the neck and upper portion of the body and lead to secondary issues in the muscles and joints of these areas. It is recommended to seek assessment from a physiotherapist who understands BPPV and the various treatment options that exist.
In some cases, BPPV will resolve spontaneously. The body has the capacity to reabsorb the otoconia or the clump of cells and things will return to normal once the crystal is gone. On the other hand, sometimes people will experience episodic or constant symptoms that can last for months or years. Even after successful treatment there is the chance that the condition will reoccur, but this can typically be resolved with the appropriate treatment.
Treatment for BPPV typically consists of the following:
Canalith repositioning maneuvers - Special positions and movements that a trained therapist can guide a patient through in an effort to relocate or dislodge a misplaced crystal or clump of cellular debris.
Exercise instruction in self-treatment and management strategies - Including self-applied movements for BPPV, balance and gait exercises, or stretching and strengthening exercises for the neck and jaw.
Education regarding the condition, the treatment, and further strategies for returning to regular activity.
Biomechanical treatment of the neck and/or jaw as required - Including hands-on therapy for the joints and muscle tissues.
The first interaction with a therapist will include a detailed assessment. It is important to understand the cause of the disorder as different kinds of treatment and therapy are not indicated for all types of dizziness. The therapist will perform a mechanical examination that can include the neck and jaw, as well as a specialized assessment of the nervous system, walking patterns, balance, and positional tests for the dizziness/vertigo. If BPPV is the diagnosis, the first treatment can often be provided during the initial assessment. Depending on the person's personal situation, exercises can sometimes be prescribed for home use to assist with recovery in between sessions with the therapist. However, as dizziness and compromised balance can be a risk factor for falls and injury, not everyone is a candidate for home exercise programming at first.
- Trent, PT
References
· Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Bhattacharyaa, N., et al. Otolaryngology - Head and Neck Surgery. 2017. Vol. 156(3s) S1-S47.
· Treatment of benign paroxysmal positional vertigo. A clinical Review. Perez-Vazquez, P., Franco-Gutierrez, V. Journal of Otology. 2017. Vol. 12 165-173.
· Vestibular rehabilitation in benign paroxysmal positional vertigo: Reality of fiction? Bressi, F. et al. International Journal of Immunopathology and Pharmacology. 2017. Vol. 30(2) 113-122.
In some cases, BPPV will resolve spontaneously. The body has the capacity to reabsorb the otoconia or the clump of cells and things will return to normal once the crystal is gone. On the other hand, sometimes people will experience episodic or constant symptoms that can last for months or years. Even after successful treatment there is the chance that the condition will reoccur, but this can typically be resolved with the appropriate treatment.
Treatment for BPPV typically consists of the following:
Canalith repositioning maneuvers - Special positions and movements that a trained therapist can guide a patient through in an effort to relocate or dislodge a misplaced crystal or clump of cellular debris.
Exercise instruction in self-treatment and management strategies - Including self-applied movements for BPPV, balance and gait exercises, or stretching and strengthening exercises for the neck and jaw.
Education regarding the condition, the treatment, and further strategies for returning to regular activity.
Biomechanical treatment of the neck and/or jaw as required - Including hands-on therapy for the joints and muscle tissues.
The first interaction with a therapist will include a detailed assessment. It is important to understand the cause of the disorder as different kinds of treatment and therapy are not indicated for all types of dizziness. The therapist will perform a mechanical examination that can include the neck and jaw, as well as a specialized assessment of the nervous system, walking patterns, balance, and positional tests for the dizziness/vertigo. If BPPV is the diagnosis, the first treatment can often be provided during the initial assessment. Depending on the person's personal situation, exercises can sometimes be prescribed for home use to assist with recovery in between sessions with the therapist. However, as dizziness and compromised balance can be a risk factor for falls and injury, not everyone is a candidate for home exercise programming at first.
- Trent, PT
References
· Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Bhattacharyaa, N., et al. Otolaryngology - Head and Neck Surgery. 2017. Vol. 156(3s) S1-S47.
· Treatment of benign paroxysmal positional vertigo. A clinical Review. Perez-Vazquez, P., Franco-Gutierrez, V. Journal of Otology. 2017. Vol. 12 165-173.
· Vestibular rehabilitation in benign paroxysmal positional vertigo: Reality of fiction? Bressi, F. et al. International Journal of Immunopathology and Pharmacology. 2017. Vol. 30(2) 113-122.
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