North 49 is a physical therapy clinic, but it is interesting as over half of the patients we see have dizziness. We see more patients each month with dizziness than back pain, neck pain, shoulder pain, knee pain or any pain for that matter combined. It is also interesting to note that our patient population is similar to what the literature finds in that with dizziness the most common cause is due to BPPV.
So what is BPPV? Let’s review some of the basics.
BPPV is short for Benign (non life threatening), Paroxysmal (sudden, uncontrollable), Positional, Vertigo (sense of spinning).
To understand what BPPV is we need to review a little anatomy. The ear itself consists of 3 sections being the outer ear, middle ear and the inner ear. The outer ear is where we get wax build up and where our doctor looks in with his otoscope. The outer ear ends at the ear drum and on the other side of the ear drum there is the middle ear that consists of 3 small bones and the eustachian tube that runs to the back of your throat.
Moving deeper we have the inner ear. In the inner ear there are 2 otolithic organs, one is called the saccule and the other the utricle.
These 2 organs are like pads that have a jelly like layer and on top of that calcium carbonate crystals which are also called otoconia or otoliths. These crystals help the inner ear detect head motion and positioning. With the inner ear it is also important to note that there are 3 semicircular canals that are very sensitive structures that help detect acceleration of the head.
So now that we have the anatomy covered we also have to remember that our body is a living organism that is always replacing itself. For example, your eye lashes grow and eventually fall off, only to be replaced by new eye lashes. Same thing with our skin and other tissues. With the inner ear the crystals flake off with time and fall to the bottom of the inner ear in an area that is not a sensitive structure. With time they gradually dissolve.
Imagine it like the crystals falling to the bottom of a snow globe. Now, if we lay back and turn our head to the side, such as when we lay back to go to sleep the position of the inner ear changes. The crystals now fall to the most dependent position just as you would see if you turned the snow globe. Unfortunately, the opening for those semicircular canals are located near the area where the crystals settle when we lay back so there is a chance that the crystals will fall into one of the 3 canals. If they do the crystals will get trapped in one of the canals and when we move the crystals will move in the canal. This stimulates the sensitive canal, resulting in dizziness and nystagmus.
If you are not sure what nystagmus is, please refer to this post.
Most often BPPV occurs for no particular reason except by chance that some crystals broke off and ended up going into one of the canals. BPPV is most often seen in seniors and this could be due to their slower metabolism to break down the crystals once they break off and/or other changes that occur with age. BPPV can also occur in younger individuals spontaneously, but more commonly occur after an inner ear infection or with a mechanism such as a whiplash or head injury that sheers some crystals off of the otolithic organ.
If you have BPPV you will experience dizziness that may or may not feel like a spinning sensation which is called vertigo. The dizziness will typically last for seconds, but at times some people have it for minutes. It is also worth noting that the dizziness can be triggered with looking up, bending forward, getting in and/or out of bed, and with rolling over in bed. It never occurs without a change in head position. After the intense dizziness that lasts for seconds goes away you may feel “off” and unsteady for a period of time.
With BPPV there should not be any other symptoms such as double vision, slurred speech, choking on foods, giving out of your legs, ear pain, pressure, ringing in the ear, or hearing loss. If you have any of these other symptoms further medical investigation would be recommended.
To determine which ear is affected the Gold Standard test is the Dix-Hallpike test. That being said, this test will only help you determine which ear is affected if the posterior or anterior canal is affected. Remember that 10-15% of the time BPPV affects the lateral canal so this needs to be assessed by another test called the Roll Test.
With performing the Dix-Hallpike and Roll Test you will be able to not only determine if someone has BPPV, but which ear, and what canal is involved. For either of these tests to be positive there will be nystagmus that accompanies the dizziness.
If you are curious how to perform these 2 tests check out this instructional video.
This is a great question that we frequently get asked. To answer this question it is best to review what the literature says. According to the Bhattacharyya (2017), the natural history of BPPV is that it will resolve spontaneously within 3 months for 50%. So, within 3 months half of the people who have it will resolve spontaneously and the other half not.
The reason that it can resolve spontaneously is that the body gradually dissolves the loose crystals, but this takes time.
Some medical practitioners prefer the “wait and see” approach. As we reviewed above with some BPPV will simply get better with time, but really who wants to wait 3 months for a 50/50 outcome? Is there another option? The answer is definitely YES!
The best treatment option is to have someone perform a canalith repositioning technique to maneuver the crystals out of the affected canal and to an area of the ear that is not sensitive. The treatment typically takes minutes to perform once the right canal is identified. The great thing is that the literature states that 84% of individuals are better after 1 visit and 97% within 3. So, why wait for days, weeks, or months to see if it will get better?
Some people call the maneuver the “Epley”, but this is a bit of a misnomer as technically the Epley not only includes the maneuver, but putting the patient in a neck collar after and providing them strict activity restricitons which research has found unnecessary.
Of note, some people are prescribed vestibular suppressants which is not recommended. The reason for this is that it does nothing for the cause of the problem. It is like taking Tylenol for a thorn in your finger. The Tylenol makes you feel better, but the thorn is still there. The best treatment in this case is to remove the thorn. With BPPV the best treatment is to remove the crystals from the canal.
Any health care practitioner trained in vestibular therapy can treat BPPV. Health care providers include, but are not limited to physical therapists, audiologists, otolaryngologists, neurologists, chiropractors, and nurse practitioners. A directory of trained care providers close to where you live can be found at https://vestibular.org/healthcare-directory/. This directory is a great resource, but only includes practitioners who have registered with the directory.
Now, if you had BPPV in the past you can also attempt the canalith repositioning technique yourself if you remember what to do. If not, or the maneuver is not helping, please seek out someone with training in this area.
BPPV can come back, but the research shows that it only comes back in up to 36% of those who had it. If it comes back it is also typically an easy fix. There are not a lot of quick fixes in rehab, but BPPV is a quick fix problem.
If you find you are having recurrent bouts of BPPV ask your health care provider how to perform the maneuver yourself. Better yet, try sleeping with your head slightly more upright. This can sometimes make a big difference in preventing it’s recurrence.
If it keeps coming back or the treatment is not effective check out this video.
If you have any other questions about BPPV, feel free to reach out to us at North 49.