“The treatment selection for most common vestibular condition – Benign Paroxysmal Positional Vertigo – BPPV”
Vestibular rehabilitation can often be effective immediately and with the use of skilled interventions we can help patient in one or two visits. One of the condition that can be treated with excellent results and bring immediate relief of symptoms is BPPV – Benign Paroxysmal Positional Vertigo. Unlike many vestibular disorders, BPPV is mechanical in nature, meaning that the reason laying behind symptoms is dislodged calcium carbonate deposits called otoconia. In many other conditions that affect vestibular system, there is either decreased or increased stimulation of the neurons and it takes some time with therapy to achieve full treatment effect. With BPPV, correcting proper otoconia position with the use of maneuvers will give great relief and bring instant results.
BPPV characterizes with free floating or adherent crystals of calcium carbonate within the inner ear canal system – the area where these particles should not be present. Otoconia normally reside within other part of the inner ear called utricle and are attached to receptors there. With age, trauma or even without any specific reason these particles can migrate from utricle to canal system and cause disturbed flow of the fluid located there during sudden head position change. There are 3 inner ears canals – anterior – more in the front and top, horizontal – in the middle and posterior – one in the bottom. 95% of dislodged otoconia will “land” in the posterior canal because of its anatomical position. Small amount of crystals can be found in patient’s horizontal canal (3%) and about 0.5% of particles can be found in anterior canal. Because of gravity pull, crystals migrate more often to posterior canal.
According to research, canalith repositioning treatment (CRT) is the most effective method of treatment of BPPV. It is simple, short in duration and brings immediate results. The most common form of treatment of BPPV is Epley maneuver. Epley maneuver is used in treatment both posterior and anterior canals variants and with free floating particles. Epley maneuver, when done correctly, could be as much as 98-100% effective, unless there is other underlying vestibular condition present. Epley maneuver is mostly used with posterior canalithiasis BPPV – the most common variant of BPPV. Each stage of the maneuver has to be performed with meticulous manner, allowing the crystals to flow within the canal the proper way. Improper CRT performance can cause migration of crystals to other canals and increase in symptoms of vertigo. BPPV characterizes in appearance of involuntary eye movement called nystagmus. By observation of nystagmus we can determine the location of crystals within the canal and their stability – free floating versus adherent to cupula which is a receptor within the canal that detects spiral moments. Usually vertigo and therefore nystagmus disappear within few seconds as crystals reach their end floating path. In these case we can chose maneuvers that treat free floating otoconia like Epley maneuver. When nystagmus or vertigo do not want to stop and are persistent for over the minute, we can suspect that the reason of the problem are crystals that are “stuck” to the canal receptor – cupula and we needs to choose other maneuver to dislodge particles from this area of canal. This condition is called cupulothiasis. The maneuver to treat posterior cupulothiasis is called Semont or “liberatory” maneuver.
Sometimes crystals can be located in horizontal canal. In this case, Epley maneuver is often unsuccessful. With horizontal canal BPPV we have to chose maneuver that will move particles within this canal like “Barbecue roll maneuver “or Apiani maneuver. Casani maneuver is used for horizontal cupulothiasis.
As we can see, treatment of BPPV can be pretty complex. Once the diagnosis is established and proper selection if treatment is initiated, we can help our patients very quickly with symptoms resolution. The knowledge about the condition and proper manual skills can be key factors in success in treatment patient with BPPV.
Please read my next blog about expectations after BPPV treatment and prevention of re-occurrence of this common vestibular condition.
Dr. Bart Roman, PT DPT
Certified Vestibular Rehabilitation Therapist