I'm often called upon to help people with Benign Paroxysmal Positional Vertigo (BPPV) - one of the most common causes of vertigo. It causes a sudden sensation of spinning, unsteadiness, vertigo, nausea and dizziness. Here is a brief overview of why it occurs and how it can be helped!
BPPV occurs as a result of displaced otoliths, which are normally attached to the otolithic membrane in the utricle.
What are otoliths?
There are two parts to our vestibular organs (provides sense of balance and information about body position)
1) the semicircular canals - sense rotational head movements
2) the otoliths - sense vertical and horizontal linear movements, head tilt, and gravity.
*Emerging research also suggests that the otoliths have a role in spatial orientation and memory.
The otoliths are again made up of two parts
1) the utricle -The utricle is oriented horizontally, so it senses horizontal motion.
2) the saccule - The saccule is oriented vertically, so it senses vertical motion.
Both the utricle and saccule contain hair cells, a gelatinous layer, and a fibrous membrane. This membrane has otoconia embedded in it. The otoconia are calcium carbonate crystals. These crystals are what give the otolith its name, as otolith is Greek for “ear stones”. The otoconia cause the membrane to be heavier than the structures and fluid around it.
When you move your head, gravity and the weight of the otoconia cause the membrane to move, which bends the hair cells, sending signals about motion and head position to the brain via the vestibular nerve.
Otoliths can detach from the utricle and collect within the semi-circular canals due to trauma, infection, ageing and unknown causes. Movement of the head causes the otoliths to inappropriately trigger the receptors in the semi-circular canals and send false signals to the brain, causing vertigo and nystagmus.
Diagnosis
It is important to distinguish between competing causes, including vertebral-basilar artery insufficiency (VBI) and BPPV, before making a diagnosis. For example, a characteristic torsional-jerk nystagmus (a slow drift of the eyes in one direction that is repeatedly corrected by fast movements in the reverse direction) may be present in patients with BPPV and not in patients with VBI.
Dizziness from cervical artery disorders has a slower onset compared to vestibulogenic disorders and usually presents after prolonged cervical positioning. Additionally, critical aspects of the history include onset of symptoms, activities producing or exacerbating symptoms, commonly a change in head position, turning in bed and C-spine flexion or extension, and the specific type of symptoms. These may include light-headedness, unsteadiness, loss of balance, blurred vision, nausea and vomiting, without hearing loss or tinnitus but with accompanying nystagmus.
Hallpike manoeuver for diagnosis of BPPV.
The dix-Hallpike manoeuver can be used in the diagnosis of BPPV. The result is positive if the patient develops vertigo and nystagmus. Symptoms can last from 10-30 seconds to several minutes, with the imbalance and nausea lasting several hours and episodes lasting for two weeks.
Treatment
The aim of treatment is to move the displaced otoliths from the semi-circular canal back into the utricle where they belong. The Epley’s manoeuvre is the most successfully used in the treatment of BPPV. It consists of a series of four quick movements of the head and body from sitting to lying, rolling over and back to sitting. Each position is maintained for at least 30 seconds or until positional nystagmus ceases.
It appears to be safe, however this should not be performed if there is presence of cervical spinal stenosis, severe kyphoscoliosis, limited C-spine ROM, Down’s syndrome, advanced R.A, cervical radiculopathies, Paget’s, morbid obesity, A.S, severe lumbar dysfunction and spinal cord injuries. As an osteopath, a thorough screening process is part of your appointment and management will depend on your medical history and examination.
Epley's manouvere
On a flat examination table with the patient seated:
1) The physician turns the patients head 45 degrees to one side, then rapidly, but smoothly lays the patient into a supine position with the head hanging over about 20 degrees over the end of the table and observes the patients eyes for approximately 30 seconds.
2) The head is rotated quickly to the left, stopping with the right ear facing upwards. This position is held for another 30 seconds.
3) The patient rolls onto the left side whilst the practitioner quickly rotates the ehad until their nose is angled towards the floor. Hold for another 30 seconds.
4) The patient is quickly lifted into a sitting position. The entire sequence can be repeated until there is no nystagmus present.
Hannah Marsh
Registered osteopath
M.Ost
GOsC 10422
References:
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diagnosis in dizzy patients. Physical Therapy and Rehabilitation. 1(3),
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Burmeister, D., Sacco, R, and Rupp, V., 2010. Management of benign paroxysmal positional
vertigo with the canalith repositioning manoeuvre in the emergency department setting. The
Journal of the American Osteopathic Association. 110(10), pp.602-604.
Moreno, J., Munoz, R., Balboa, I., Matos, Y., Agudelo, O., Vasudeva, A., Aguilera, O.,
Ortega, J., Guillen, A., Olaya, C., Curto, X., Perez, E., Ripolles, C., Palacios, P., Farres, N.,
Sanchez, A., Cantera, C, and Ledesma, R., 2014. Effectiveness of the Epley’s manoeuver
performed in primary care to treat posterior canal benign paroxysmal positional vertigo:
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doihttps://doi.org/10.1186/1745-6215-15-179
Hilton, M, and Kinder, D., 2014. The Epley (canalith repositioning) maoeuvere for benign
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DOI:10.1002/14651858.CD003162.pub3
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