When I first began treating benign paroxysmal positional vertigo (BPPV), I was advised to: “Always keep a hold on the patient after sitting them up.” It was a warning about the potential for dizziness caused by otolith movement (postural crisis after BPPV treatment) or, more often, due to blood pressure changes during the final step of the maneuver.
Over the years, I’ve followed that advice religiously, wrapping both of my arms around the patient’s neck and shoulders, holding them briefly while making small talk and checking how they are doing.
That is, until one time I didn’t.
I had just completed a modified Epley maneuver with a patient. He looked stable, so I stepped back. But about 15 seconds later, he suddenly started to lose postural control and began to flail backward. Fortunately, I caught him before he fell off the treatment table. The whole incident was caught on video, a humbling reminder that a postural crisis after BPPV treatment can happen even when things appear calm.
Thankfully, the patient was not injured and actually felt better after the maneuver. This could have, however, ended much worse.
Although I was advised to hold onto my patients after sitting them up, I cannot recall anyone ever telling me how long to hold them. Curious, I asked a couple of colleagues who recently completed their vestibular training at Emory University, and they both confirmed that no specific duration was mentioned in their course either. Because of this, and the risks involved, this blog will offer some time-based recommendations based on the most current literature at the time of writing.
A postural crisis, also referred to as a Tumarkin-like phenomenon, is a sudden, involuntary loss of postural control that can occur after a canalith repositioning procedure (CRP), such as the modified Epley or Semont maneuver. It typically happens during the transition from the final supine position to upright sitting and is not accompanied by loss of consciousness.
Patients may appear stable initially and then suddenly experience a falling sensation or collapse within seconds.
Unlike earlier steps in the maneuver, where the otoconia move more gradually through the semicircular canal, the final step of the canalith repositioning technique, if done successfully, is having the otoconia leave the canal and enter the utricular portion of the vestibule. Now if the otoconia land on or near the utricular macula, they cause a rapid deflection of the hair cells embedded within the otolithic membrane. This sudden mechanical stimulation mimics the sensation of intense linear acceleration or a sudden change in head position. The brain interprets this unexpected input as a significant shift in body orientation, which can trigger powerful, involuntary postural reflexes resulting in the Postural Crisis (Tumarkin-like phenomenon) seen in some patients.
This rapid utricular activation in one ear may explain why the final transition from supine to sitting is more provocative than the other steps and why, when a postural crisis occurs, some clinicians view it as a positive indicator that the otoconia have successfully exited the canal. Kim et al. (2025) suggest that a Postural Crisis likely reflects effective repositioning into the utricle.
However, Yang & Yang (2025) caution that the literature does not support blanket statements. Their review highlights that outcomes may vary, and a Postural Crisis does not universally confirm treatment success.
According to Yang & Yang, observation of nystagmus direction, when possible, may help clarify whether the otoconia are moving out of the canal (supporting a successful maneuver) or back into the canal (suggesting incomplete or misdirected repositioning):
Upbeat torsional nystagmus (same direction as seen during the Dix-Hallpike) suggests the otoconia are exiting the canal, supporting a successful outcome.
Downbeat torsional nystagmus (opposite direction) may indicate the otoconia are moving back into the canal, or potentially into the anterior canal.
The challenge, however, is that in these rare events when a Postural Crisis response occurs, your priority is securing the patient, not interpreting eye movements. Flailing limbs and panic can make nystagmus observation nearly impossible. In these cases, repeating the Dix-Hallpike test after confirms the treatment outcome.
Personally, and rightly or wrongly, I open the eye piece of the infrared goggles during the third step of the modified Epley so that when the patient sits up, they have a visual reference to help reorient themselves. This, however, means I am not able to observe and record eye movements during the final transition to upright with the goggles.
In Kim et al.’s analysis of 1,177 patients who underwent CRP for posterior canal BPPV, 10% experienced a postural crisis (Tumarkin-like phenomenon). Individual study rates ranged from 4% to nearly 15%, suggesting it’s more common than many clinicians might expect.
Latency: Can occur up to 30 seconds after sitting up
Symptoms: Dizziness/vertigo, falling sensation, inability to maintain posture
Behaviour: Patients may scream, flail, or collapse, often startling both themselves and the clinician
Nystagmus:
Upbeat torsional: Otoconia exiting canal
Downbeat torsional: Otoconia moving back into the canal
Both Yang & Yang and Kim et al. recommend these precautions to reduce the risk of postural crisis:
Hold the patient securely for at least 30–60 seconds after sitting up
Watch for downbeat nystagmus, which may precede postural collapse
Use proper head positioning throughout the maneuver. Poor technique increases the risk of otoconia entering the wrong canal
Explain the risk of dizziness or instability to the patient beforehand
Avoid stepping away, even if the patient appears stable
After that close call, I have doubled down on my process:
I keep both arms around the patient’s neck and upper shoulders while sitting them up
I stay there for at least 30 seconds, chatting with them and watching for signs of instability
I do not walk away even when everything looks fine until I’m confident they are truly okay
Postural Crisis or a Tumarkin-like phenomenon after BPPV treatment is rare, but it is real. It can happen suddenly, without warning, and result in serious injury if the therapist is not prepared.
I was lucky. I caught my patient. But had I not been paying attention, that story and his outcome could have been very different.
So whether you are early in your vestibular practice or a seasoned clinician: stay close, stay engaged, and hang on.
For further vestibular education, feel free to check out our website at:
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