
Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common causes of dizziness, particularly in older adults. It is a condition that originates from the inner ear and causes brief episodes of vertigo— a sensation of spinning— triggered by changes in head position. Vestibular rehabilitation plays a vital role in the effective management and resolution of BPPV. This blog delves into BPPV and highlights how physiotherapy interventions can restore balance and alleviate symptoms.
What is BPPV?
BPPV occurs when tiny calcium carbonate crystals (otoconia) become dislodged from their usual location in the utricle of the inner ear and migrate into one of the semicircular canals. These canals are filled with fluid and detect rotational movements. The presence of these crystals disrupts the normal flow of fluid, sending false signals to the brain and causing vertigo.

1. Intense, Brief Episodes of Vertigo
What It Feels Like:
• A sudden, intense sensation that the environment is spinning around you or that you are spinning within the environment.
• These episodes typically last for a few seconds to a minute but can feel much longer due to the overwhelming nature of the sensation.
Why It Happens:
• The semicircular canals in the inner ear detect rotational movements. In BPPV, dislodged calcium crystals (otoconia) in these canals disturb the normal fluid movement, causing the brain to perceive false signals of movement.
• This mismatch between visual input and inner ear signals triggers the vertigo.
Impact on Daily Life:
• Sudden vertigo episodes can disrupt activities like standing, walking, or driving and may lead to accidents or injuries.

2. Dizziness Triggered by Specific Head Movements
What It Feels Like:
• A lightheaded or woozy sensation often occurring when changing head positions.
• Common triggers include lying down, sitting up, turning over in bed, looking up (e.g., to reach for something on a high shelf), or bending down.
Why It Happens:
• The dislodged crystals move within the semicircular canal fluid when the head changes position, activating sensors inappropriately.
• This false signalling confuses the brain, leading to dizziness.
Impact on Daily Life:
• People may avoid certain movements or postures for fear of triggering dizziness, which can interfere with tasks like tying shoes, cleaning, or even sleeping comfortably.

3. Nausea or Vomiting
What It Feels Like:
• A queasy feeling in the stomach, often accompanied by a strong urge to vomit.
• Some individuals may vomit after severe or prolonged vertigo episodes.
Why It Happens:
• The vestibular system works closely with the brain’s vomiting center (in the medulla oblongata). When the vestibular system sends confusing signals, it can overstimulate this centre, leading to nausea or vomiting.
• This reaction is a protective mechanism but can exacerbate the overall discomfort.
Impact on Daily Life:
• Nausea can lead to dehydration or malnutrition if severe or frequent. It can also prevent individuals from engaging in normal activities due to fear of discomfort.

4. Unsteadiness or Loss of Balance
What It Feels Like:
• A sensation of being off-balance, as if the ground is shifting beneath you.
• Difficulty maintaining a stable posture, especially when walking, standing, or performing tasks requiring coordination.
Why It Happens:
• The inner ear provides essential input to the brain for balance. When the vestibular system malfunctions due to BPPV, this balance information becomes unreliable, leading to unsteadiness.
• The brain may rely more on visual or proprioceptive cues (from muscles and joints) for balance, which can be less effective in dynamic situations.
Impact on Daily Life:
• Unsteadiness can increase the risk of falls, particularly in older adults or those with pre-existing mobility challenges.
• Fear of falling can lead to a reduction in physical activity and a decline in overall fitness, exacerbating the problem.
Psychological Impact of BPPV Symptoms
While the physical symptoms of BPPV are well-documented, they also take a toll on mental health:
• Anxiety and Fear:
Sudden and unpredictable vertigo episodes can cause anxiety about when the next episode might occur.
• Loss of Confidence:
Individuals may feel unsafe performing daily tasks, leading to social withdrawal or dependence on others.
• Depression:
Chronic dizziness or the inability to enjoy normal activities can negatively affect mood and quality of life.
Diagnosing BPPV
Physiotherapists and healthcare professionals diagnose BPPV using clinical tests such as:
1. Dix-Hallpike Test: Involves specific head and body movements to provoke vertigo and observe nystagmus (involuntary eye movements) to identify the affected ear and canal.
2. Roll Test: Used to detect horizontal canal involvement.These assessments are crucial in determining the canal involved and tailoring treatment.
3. Observing Nystagmus: Nystagmus is a key indicator of BPPV, as it reflects abnormal vestibular system activity.
4. Functional Balance and Gait Assessments: Although BPPV is positional in nature, physiotherapists may also assess balance and functional mobility to evaluate the broader impact of the condition.
Physiotherapy Management of BPPV
Vestibular rehabilitation offers highly effective, non-invasive treatments for BPPV, primarily involving repositioning manoeuvres .

1. Re-positioning Epley Manoeuvre: Effective for posterior canal BPPV, this series of head and body movements helps move the crystals out of the semi-circular canal.

Brandt-Daroff Exercise: The Brandt-Daroff exercises are simple, home-based movements designed to treat Benign Paroxysmal Positional Vertigo (BPPV). These exercises help reposition displaced calcium crystals (otoconia) in the inner ear and reduce dizziness by desensitizing the vestibular system to positional changes.
2. Gaze Stability Exercises
While gaze stability exercises are commonly used for general vestibular dysfunction, their role in Benign Paroxysmal Positional Vertigo (BPPV) is more nuanced. Gaze stability exercises can be beneficial in managing lingering symptoms such as dizziness, imbalance, or visual-vestibular mismatch after the otoconia have been repositioned.
Why Use Gaze Stability Exercises in BPPV?
• Post-Treatment Recovery: Some patients experience residual dizziness or instability even after successful repositioning manoeuvres.
• Improved Vestibulo-Ocular Reflex (VOR): Strengthening VOR helps stabilize vision during head movements.
• Adaptation: Repeated head and eye coordination retrains the brain to adapt to new vestibular signals.
• Functional Balance: Enhances confidence and reduces fear of movement in daily activities.

4. Education and Advice
Physiotherapists guide patients on:
• Avoiding sudden head movements immediately after treatment.
• Managing recurrence with self-repositioning techniques.
• Identifying triggers and reducing their impact on daily life.
Outcomes of Physiotherapy for BPPV
With appropriate intervention, BPPV is highly treatable, with symptom resolution often achieved in just one or two treatment sessions. The benefits include:
• Rapid relief from vertigo episodes.
• Restoration of balance and confidence in movement.
• Reduced risk of falls and injuries.

Preventing Recurrence
While BPPV can recur, adopting certain lifestyle changes may help minimize episodes:
• Stay hydrated to support overall vestibular health.
• Avoid prolonged positions that may dislodge crystals, such as lying flat for extended periods.
• Engage in regular exercise to maintain balance and stability.
Conclusion
BPPV, though distressing, is a manageable condition with the right physiotherapy approach. Techniques like the Epley manoeuvre and tailored vestibular exercises provide rapid and effective relief, enabling patients to return to their daily activities without fear of vertigo episodes.
If you suspect you have BPPV, consult a physiotherapist trained in vestibular rehabilitation. With the proper care and guidance, you can restore balance and live confidently, free from the spinning world of vertigo.
Written by Shiny Vijay, Senior Physiotherapist, HomePhysio By Nicola Ltd
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