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Benign paroxysmal positional vertigo (BPPV)

What is Vertigo?

The most common cause of Vertigo is a condition called Benign Paroxysmal Positional Vertigo (BPPV)

  • Benign – not dangerous or likely to cause lasting effects

  • Paroxysmal – rapid onset, reaches a peak and then slowly goes away

  • Positional – triggered by changes in head position

  • Vertigo – abnormal sensation of movement – world or self

The inner ear balance system: The entire inner ear system, cochlea (hearing) and vestibular (balance) apparatus, is encased in bone inside the skull and consists of delicate membranes filled with fluid.

The inner ear consists of 5 balance organs.

  • 3 motion sensors call the semi-circular canals (horizontal, posterior and anterior canals). These canals are filled with fluid and contain motion sensitive hair cells.

  • 2 structures which sense gravity and tilt called the utricle and saccule.

Moving the head makes the fluid flow through the semi-circular canals and stimulates the motion sensitive cells. This enables the brain to interpret direction and speed of head movement. The inner ears help control the eyes during head movement to maintain focus. When there is an inner ear dysfunction, it causes a reflex eye movement called Nystagmus. The brain perceives this eye movement as a sense of motion so you experience dizziness i.e. vertigo.

What happens in BPPV?

Small crystals of calcium carbonate are normally attached to the utricle and saccule in the inner ear and help the brain sense gravity. These crystals frequently fall off into the fluid following a head trauma, viral infection or as a part of the ageing process. They drift into the semi-circular canals where they do not belong.

The presence of these crystals with the semi-circular canals causes abnormal stimulation of the nerve endings when the head is moved and you experience vertigo.

Common triggers of BPPV

  • Getting in and out of bed

  • Rolling over in bed

  • Washing your hair in the shower

  • Bending over  in the garden

  • Looking up or down into cupboards

  • Hanging clothes on the line

  • Looking down while reading or
    doing the washing up

  • Climbing up and down ladders

  • Standing up or turning quickly

Characteristics of BPPV

  • The vertigo is typically brief usually lasting no more than 10 -20 seconds.

  • The attacks usually occur in bouts which may last for 2-3 days or persist for weeks or several months at a time.

  • Usually symptoms are worse in the mornings.

  • Other symptoms may include nausea, vomiting, a sense of being off balance and light headedness.

  • Hearing loss should not occur in BPPV. If you have noticed recent hearing loss in one ear, alert your GP as you should be sent for a hearing test to rule out more serious problems.

  • Each semi-circular canal will cause a specific reflex eye movement when affected by BPPV. The direction of these eye movements tells the therapist which ear is affected and which cancel the problem is in.

  • BPPV can affect both ears at the same time but this is relatively rare and is usually seen after some type of head injury or fall.

Following treatment

  • Keep your head still for approximately 30 mins after the treatment to allow for the crystals to reabsorb (do not lie down, bend over etc ) After 30 mins you can resume your normal activities.

  • In mild cases where the clinician has been unable to determine which canal is affected, you will be given some exercises to do each day until symptoms clear.

  • Usually once the debris has been moved out of the canals, the residual symptoms of light headedness, nausea and imbalance will disappear in a couple of days.

  • When BPPV has been successfully treated and you are clear of symptoms make sure you get on with life and forget about the BPPV, no matter how debilitating it may have been.

  • Physical activity such as walking can help in recovery.

Treatment of BPPV

  • The treatment involves procedures called particle repositioning manoeuvres.

  • These manoeuvres involve turning the head in different directions to move the crystals out of the canal to be reabsorbed over time.

  • Particle repositioning manoeuvres are the most effective treatment for BPPV.

  • In most cases, the manoeuvres are successful on the first attempt. In persistent cases it can take two or more repositioning manoeuvres.

  • In some cases, during the repositioning manoeuver the crystals may move out of one canal and into another. This can take longer to clear.

Will BPPV come back again?

BPPV can occur as an isolated event but it does have a tendency to reoccur. If it does either see your GP or return to Physiotherapist. Nothing can be done to stop recurrent bouts of BPPV so do not limit your activities just in case it does come back!

In rare cases BPPV is resistant to treatment. Exercises can help minimise symptoms. Surgery is RARELY required or recommended.

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