BPPV Test

What is benign paroxysmal positional vertigo?

Benign paroxysmal positional vertigo, or BPPV for short, is one of the most common inner ear disorders. It’s also considered one of the primary causes of vertigo, a strange and disturbing sensation where the person with it will feel as if the world around them is spinning and moving in all directions, even if they’re standing still.

Episodes of brief dizziness characterize BPPV, and the severity of the dizziness varies from episode to episode, from mild to debilitating.

BPPV symptoms:

A person with benign paroxysmal positional vertigo will likely have the following symptoms:

• Nausea and vomiting
• Lightheadedness
• Dizziness
• Loss of balance and the feeling of instability
• Vertigo (feeling that the world around you is spinning)

While this might sound nothing terrible to some, benign paroxysmal positional vertigo should not be taken lightly because it can cause intense distress and increased risk of falling, which, in turn, heightens the risk of unwanted and preventable injuries that one can sustain if they do fall. Falling can be life-threatening, so it would be best to take BPPV seriously.

What causes BPPV?

Benign paroxysmal positional vertigo occurs when the crystal substances in our ears, known as otoconia, become dislodged from their original positions and become displaced in our inner ear and enter areas like semicircular canals (often the posterior semicircular canal).

Once they enter such areas and we make head position changes like looking up or down, or whenever we adjust our positions while lying down, the crystals will move to the lower part of the semicircular canal, allowing fluid to enter the canal.

The fluid that enters the canal will stimulate the eighth cranial nerve, which is the cranial nerve responsible for balance. When this cranial nerve gets stimulated by fluid, it will cause vertigo and nystagmus (a condition characterized by our eyes having uncontrollable, repetitive movements).

This generally happens when a person has BPPV, but what can cause these otoconia to be dislodged and displaced in the first place? Here are some examples:

• Head trauma or head injury
• Keeping the head in the same position for too long and then making a sudden head movement
• Inner ear problems like inflammations or infections (e.g., labyrinthitis, acoustic neuroma)
• Exercises like riding a bicycle on bumpy terrain or practicing high-intensity aerobics
• The degeneration of the vestibular system over time due to aging

What are examples of BPPV Tests?

For healthcare providers to ascertain if a patient has benign positional vertigo, they can conduct the following tests, both of which are simple and specific maneuvers:

The Dix-Hallpike maneuver

This is one of the most common diagnostic tests for benign paroxysmal positional vertigo. To perform this maneuver, the professional must do the following:

• The patient sits down on an examination bed or table.
• They will have the patient turn their head 45 degrees to one side
• They will instruct the patient to keep their eyes open while their head is turned
• They will then assist the patient in transitioning from a sitting position to having them lie down in a supine position while maintaining their head turned
• They will position the patient's head in such a way that one of the patient’s ears is pointing to the floor
• They will support the patient’s head to avoid straining it, all while observing their eyes for two minutes
• If nystagmus occurs within those two minutes and the professional believes that it corresponds with the suspected affected semicircular canal, the professional can make a clinical diagnosis and designate the patient with BPPV

If the patient doesn’t make involuntary eye movements, they might have something else causing vertigo instead of BPPV. In order to make an accurate diagnosis, physical therapists can conduct other tests to check if other problems are causing vertigo in a patient, especially if they've ruled out BPPV as the cause.

Supine roll maneuver for lateral canal BPPV

The Supine Roll Maneuver, sometimes called the Supine Roll Test, is similar to the Dix-Hallpike Maneuver. This involves the following:

• Having the patient lie down
• The healthcare professional will turn the patient’s head 90 degrees to one side and flex it approximately 20 degrees forward, all while the patient keeps their eyes open
• The physical therapist or similar professional will observe the patient’s eyes for 30 seconds before doing the same when the head is turned 90 degrees in the opposite direction
• The patient is positive for (lateral) BPPV if there is horizontal nystagmus (involuntary side-to-side eye movements)

What are examples of treatments for BPPV?

BPPV treatment involves specific vestibular rehabilitation exercises that involve a lot of head movement. These are primarily particle repositioning exercises, which are repositioning maneuvers for treating the problem and alleviating a patient's symptoms (e.g., feeling a spinning sensation or dizziness). Here are some examples:

Gufoni maneuver

This maneuver is meant to help patients with benign paroxysmal positional vertigo (BPPV) from the lateral semicircular canals. This requires knowing the affected side, which you can do by doing the Supine Roll Maneuver we discussed earlier. Once you have determined the ear involved, you can perform this maneuver. You must have the patient sit on an examination bed first to perform this. Then:

1) If they have geotropic nystagmus (horizontal nystagmus that beats towards the floor):

• Gently put them in a straight side-lying position on the unaffected side and keep them in that position for 30 seconds.
• After 30 seconds, quickly (but gently) turn their head 45 to 60 degrees toward the ground and hold that position for one to two minutes.
• After one to two minutes, put them seated while keeping their head held toward the shoulder until they're fully upright.
• Once they're upright, straighten their head position

2) If they have apogeotropic nystagmus (horizontal nystagmus that beats away from the floor):

• Gently put them in a straight side-lying position on the affected side and keep them in that position for 30 seconds.
• After 30 seconds, quickly (but gently) turn their head 45 to 60 degrees toward the ground (if the otoconia are on the utricular side) or upward (if the otoconia are on the canal side of the cupula) and hold that position for one to two minutes.
• After one to two minutes, put them seated while keeping their head held toward the shoulder until they're fully upright.
• Once they're upright, straighten their head position.

The Epley maneuver (canalith repositioning procedure) for posterior canal BPPV:

This can be performed without a physical therapist. To perform the Epley Maneuver, a person needs a pillow, and they must do the following:

• Sit on the edge of the bed and place the pillow so that when they lie down later, the pillow will be resting between their shoulders.
• Turn their head 45 degrees to the left/right (whichever side is affected) and lie on their pillow.
• Lie down on their back with their head on the bed and still positioned 45 degrees to the affected side. They must maintain this position for 30 seconds until the vertigo disappears.
• After 30 seconds, they must turn their head in the opposite direction by 90 degrees without raising their head. They must maintain this position for 30 seconds.
• After 30 seconds, they must turn their head to look at the floor and maintain that position for 30 seconds.
• After 30 seconds, they must slowly sit up and remain seated on the bed for a few minutes.
• It's recommended to do this three times before sleeping each night until they no longer experience dizziness for a whole day.

Log roll maneuver for horizontal canal BPPV

This one is easy! The person must assume the following positions in order, and they must maintain these positions for 30 seconds each:

• Assume a straight side-lying position with their affected ear facing down.
• After 30 seconds, they must assume a supine position.
• After 30 seconds, they must assume another straight side-lying position, this time with their affected ear facing up.
• After 30 seconds, they must assume a prone position.
• After 30 seconds, they must sit upright with their knees and hands on the floor while looking at the floor.

Doing this once or twice a day for a whole week is recommended.

Yacovino maneuver for anterior canal BPPV

This requires a bed. The person performing this must do the following:

• Sit upright on the bed with their head straight.
• Quickly lie down in a supine position and have their head hang 30 degrees below horizontal (the corner of the bed should support the neck).
• They need to maintain this position to treat dizziness. Once their dizziness disappears, they must maintain this position for 30 seconds more.
• After 30 seconds, they must quickly flex their head and make sure their chin touches their anterior chest. They must maintain this position for 30 seconds.
• After 30 seconds, they must move into a long-sitting position with their head in a neutral position.

Semont maneuver

For this maneuver, the person performing it must do the following:

• Sit on the edge of their bed.
• Turn their head 45 degrees to the affected side.
• Quickly lie down in a straight side-lying position on the affected side, and maintain their position for 30 seconds.
• After 30 seconds, they must quickly move to lie down on the opposite end of their bed without changing the direction of their head. They must lie in their new position for 30 seconds while looking at the floor.
• After 30 seconds, they must slowly return to a seated position and just sit there for a few minutes.

Foster maneuver

For this maneuver, the person performing it must do the following:

• They must kneel and look up at the ceiling for a few seconds (let's go with 10).
• Then, they must touch the floor with their head while tucking their chin so that their head looks like it's going towards the knees. They must maintain this position until their vertigo stops, then wait for 30 more seconds.
• After 30 seconds, they must turn their head toward the affected side, facing the elbow. They must maintain this position for 30 seconds.
• After 30 seconds, they must quickly raise their head until it's leveled with their back while on all fours. They must maintain their head at a 45-degree angle and maintain it at that angle for 30 seconds.
• After 30 seconds, they must quickly raise their head until it's fully upright while turning it to the affected side. Then, they will slowly stand up.
• It's best to repeat this a few times (up to the person) with 15 minutes of rest between each repetition.

Surgical treatment

If none of the maneuvers above work, then physical therapists might recommend patients to undergo surgery. Such cases are rare, but if it comes to this, the surgeon will perform a procedure where they will block the posterior semicircular canals using a plug to prevent the otoconia from entering it. Please note that people who undergo this procedure run the risk of hearing loss.

Another type of surgery is semicircular canal occlusion. This entails the ear drum reconstruction to help alleviate BPPV symptoms. Those who undergo this surgical procedure will run the risk of sustaining hearing loss (temporary for some people), tinnitus, and facial nerve damage.