What is vertigo?

Vertigo is a broad term used to describe an illusionary sense of motion in the absence of true motion [1] Benign paroxysmal positional vertigo (BPPV) is a specific disorder of the inner ear which results in spinning sensations with changes in head position [1,2]. BPPV can be caused by head trauma/infection of a vestibular nerve (vestibular neuritis) and other complications in the inner ear related to illness or surgery, however, most cases of BPPV do not have a specific cause (idiopathic BPPV) [1,2]. The semicircular canals (anterior, posterior and lateral) in the inner ear which are filled with fluid (endolymph) that moves in response to rotation of the head which bends the cupula hair cells which stimulates vestibular nerves [1,2].

The two most common types of BPPV are BPPV of the posterior semicircular canal (posterior canal BPPV) or BPPV of the lateral semicircular (horizontal canal BPPV). The main mechanisms of BPPV are thought to be:

  1. Canalisthiasis – where free-floating debris in the semicircular canal causes continuous movement of the endolymph after movement has stopped which causes bending of the cupula and provokes vertigo [1-3]

  2. Cupulolithiasis – where abnormal debris attaches to the cupula making it more sensitive to gravity and provoking vertigo [1-3]

 

How is BPPV diagnosed from other causes of vertigo?

It is important that the specific cause of vertigo is identified to ensure effective treatment or management of symptoms. Other causes of vertigo include but are not limited to:

  • Other disorders related to the ear (otologic disorders) – e.g. Meniere’s disease [1]

  • Neurologic disorders – e.g. Demyelinating disease, central nervous system lesions, stroke [1]

  • Anxiety/panic disorders [1]

  • Cervicogenic vertigo (related to the neck) [1]

  • Side effects from medication [1]

  • Postural hypotension (low blood pressure) [1]

  • Other medical conditions – e.g. toxic, infectious or metabolic conditions [1]

There are specific criteria required to diagnose BPPV – these relate to both the patient’s history and the physical examination. 

 

Patient history

Patients with BPPV report episodes of vertigo associated with changes in head position relative to gravity [1,2] Common provoking activities include rolling over in bed, moving head to look upward and bending forward.1,2  

 

Physical examination

Physical manoeuvres are used to confirm presence of BPPV and identify the affected canal clinically. The Dix-Hallpike manoeuvre is used to confirm posterior canal BPPV [1-3]. During the Dix-Hallpike manoeuvre a patient is rapidly moved from sitting to lying position with the head tilted to 45 degrees below horizontal, 45 degrees to the side of the affected ear and downward [1]. The Roll test is used to diagnose lateral canal BPPV [1-3]. The Roll test is performed with the patient lying on their back with head starting in neutral position and turned rapidly to the right side, observing for symptoms, returning to face up position, and then turned rapidly to the left and observing for symptoms.1 In patients with BPPV these manoeuvres provoke vertigo and nystagmus (rapid, involuntary movement of the eyeball) [1-3]

How can BPPV be treated?

Surgery is not recommended or necessary unless it is to address a specific underlying cause (e.g. disease, illness), or there is the occurrence of severe, frequent, recurring episodes without any reduction or remission with other treatment options [1,2] Medication is also not necessary for treatment of BPPV but may be used to manage associated symptoms such as nausea or vomiting [1].

Although many cases of BPPV resolve spontaneously without treatment, some patients experience ongoing symptoms and may experience balance problems which can restrict activities and affect quality of life [1,2].

Current evidence supports the use of canalith repositioning (CRP) manoeuvres as initial treatment for BPPV [1-4]. CRP manoeuvres are performed on the patient and involve moving the patient’s head through a series of positions and using gravity to help move free-floating debris out of the affected semicircular canal [1,2]. CRP manoeuvres can be performed by any health professional in the outpatient setting, including physiotherapy [1,2]. The most commonly used and recognised CRP manoeuvre is the Epley’s manoeuvre which is effective in resolving symptoms in a small number of treatments (usually 1-3) [1,2].  Incorporation of vestibular rehabilitation with CRP manoeuvres is useful for long term management to promote functional recovery and/or as preventive measure [1,3,4]. Vestibular rehabilitation involved exercise- and movement-based interventions performed by the patient, they focus on challenging and promoting adaption of the nervous system to compensate for vestibular dysfunction [3].

 

If you have any questions regarding vertigo and dizziness, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

References

  1. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). J Otolaryngology – Head Neck Surgery. 2017;156(3_suppl):S1-S47.

     

  2. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews. 2014(12).

     

  3. Rodrigues DL, Ledesma ALL, de Oliveira CAP, Júnior FB. Physical Therapy for posterior and horizontal canal benign paroxysmal positional vertigo: Long-term effect and recurrence: A systematic review. J International archives of otorhinolaryngology. 2017.

     

  4. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2015(1).

     

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