At the beginning of my physical therapy career I remember patients treated for many different conditions who complained of having symptoms of vertigo. Patients stated “please do not lay me down flat because I feel so dizzy in this position”. I couldn’t understand this at the beginning but I realized that it can be very uncomfortable for a person to not tolerate changing position without getting “dizzy”. After further education, I realized that physical therapy treatment for this condition, called Benign Paroxysmal Positional Vertigo, can be very effective. As stated in previous blog, we can help patients a great way and relieve symptoms instantly with canalith repositioning maneuvers. The down side of it is that these symptoms often come back.
Unfortunately, Benign Paroxysmal Positional Vertigo – BPPV is highly reoccurring condition and according to the research, symptoms can come back to as much as in 50% of cases treated for it. BPPV is a mechanical condition in nature and dislodged calcium carbonate crystals can migrate freely from utricle to canal system with sudden or even not rapid position change.
The most important piece of advice is that we don’t have to be afraid of these symptoms as they can be treated with physical therapy. Canalith repositioning maneuvers is the only effective way of treatment of this condition and with skilled intervention, symptoms can be gone is as little as 10 minutes. More information about management of BPPV You can find in previous blog dated September 28, 2018.
The questions remains: is there anything we can do to prevent BPPV from reoccurrence? Well, staying in upright position and not changing it will do the job but is there really a sense to be afraid to move the body if the real way to treat this condition is a movement? After treatment of BPPV, many patients refrain from moving towards affected side like sleeping on one side and do it sometimes for years. Not moving toward affected side and staying away from head rotations will cause even more crystals to accumulate and therefore problem persists. It is highly recommended to continue to move head all directions and lay down on various sides to help “dissolve” the calcium carbonate deposits if they are still present after the canalith repositioning maneuver.
What do vestibular rehabilitation therapists do after they perform canalith maneuvers and successfully treat BPPV? Many years ago the notion was to not move head to let crystals settle in the utricle. Many clinicians asked patients to not lay flat and sleep in the recliner up to a week. Additionally, soft collar was recommended to avoid head rotations. That caused a lot of discomfort and physical and mental scare. Patients thought that after the precautions are lifted, any movement will trigger BPPV again. Scientist lately concluded that actually there is no need for post maneuver precautions to be performed as reoccurrence of BPPV is in the same rate as whether patient follows or doesn’t follow them. It is only recommended to not lay down flat for the next 4 hours and avoid rapid head movements for this short duration of time. In my practice I follow this rule and actually see good outcomes with my patients. Only a small percentage of patients return to my office with reoccurrence of BPPV within the same week after repositioning. Majority of patients are comfortable with these precautions and return to lie down on affected side when they go to sleep the night of the maneuver.
Concluding, we have to understand that BPPV is a “benign” condition and should be explained to a patient as something “curable”. Refraining from moving towards directions that trigger symptoms can only bring more psychological impairments and prevent from calcium carbonate crystals to dissolve and reposition on their own. Additionally, we can help the symptoms to go away with the use of habituation exercises. My next blog will be devoted to explain the use of these wonderful exercises in treatment of BPPV and other conditions that cause positional dizziness.
Dr. Bart Roman, PT DPT
Certified Vestibular Rehabilitation Therapist