BPPV

PHYSIOTHERAPY MANAGEMENT OF
BENIGN PAROXYSMAL POSITIONAL

VERTIGO (BPPV)
by
Neurology/Medicine Unit
Department of Physiotherapy
31/08/2022
Definition
Types
Clinically Relevant Anatomy
Etiology/Causes
Prevalence
Clinical Presentation
Diagnostic Procedures
Medical Management
Physiotherapy Management
References
Definition
Types
Etiology/Causes
Prevalence
Medical Management
References
Definition
Types
Etiology/Causes
Prevalence
Medical Management
References
Definition
Types
Etiology/Causes
Prevalence
Medical Management
References
Definition
Types
Etiology/Causes
Prevalence
Medical Management
References
Definition
Types
Etiology/Causes
Prevalence
Medical Management
References
Definition
Types
Etiology/Causes
Prevalence
Medical Management
References
Definition
Types
Etiology/Causes
Prevalence
Medical Management
References
Definition
Types
Etiology/Causes
Prevalence
Medical Management
References
Definition
Types
Etiology/Causes
Prevalence
Medical Management
References
Definition
Most
common
cause
of vertigo
(Shim et al., 2014)

Vertigo: a
symptom of
the condition
(Shim et al., 2014)

Best defined by
words in acronym
(Shim et al., 2014)

1. Benign…not
harmful in effect
(Shim et al., 2014)

2. Paroxysmal…sudden
intensification of
symptom (vertigo)
(Shim et al., 2014)

Paroxysm:
sudden attack of
particular activity
(Shim et al., 2014)

3. Positional…related
to/determined by
head spatial position
(Physiopedia, 2022)
4. Vertigo…type of
dizziness…feeling
that one/the world is
spinning around
(Health Direct, 2022)

Affects all ages

Middle ear pathology
cause in younger
patients

Central & Peripheral
Causes
(Stanton & Freeman, 2021)

Peripheral Causes:
(Stanton & Freeman, 2021)

Peripheral Causes:
BPPV & Meniere’s Dx
(Physiopedia, 2022)
Central Causes:
(Physiopedia, 2022)
Central Causes:
Ischaemic &
Hemhorragic Strokes
(Physiopedia, 2022)
Central Causes:
Ischaemic &
Hemorrhagic Strokes
involving cerebellum &
vertebrobasilar system
(Physiopedia, 2022)
Central Causes:
Tumors, Vestibular
Migrains & Multiple
Sclerosis
(Physiopedia, 2022)
Types
2 MAJOR TYPES:
(Bhattacharyya et al., 2017)

2 MAJOR TYPES:
BASED ON THE TYPE
OF NYSTAGMUS
(involuntary eye movt.)

a. Posterior
semicircular
canal BPPV
(Soloman, 2000; Bhattacharyya et

al., 2017; Imai et al., 2017)
a. Posterior
semicircular
canal BPPV
b. Horizontal/Lateral
semicircular canal
BPPV
al., 2017; Imai et al., 2017)
a. Posterior
semicircular
canal BPPV
- Most common type
(Soloman, 2000; Bhattacharyya et al., 2017; Imai et al.,

2017)
a. Posterior
semicircular
canal BPPV
- Posterior
Semicircular canal
2017)
a. Posterior
semicircular
canal BPPV
- Dix-Hallpike Test

al., 2017; Imai et al., 2017)
a. Posterior
semicircular
canal BPPV
- Upbeat Tortional
Nystagmus during
test
2017)
al., 2017; Imai et al., 2017)
a. Posterior
semicircular
canal BPPV
- Latency of onset of
nystagmus b/w 2-20 secs
al., 2017; Imai et al., 2017)
a. Posterior
semicircular
canal BPPV
- Nystagmus intensity
increases and resolves
within a minute.
2017)
a. Posterior
semicircular
canal BPPV
- Nystagmus fatigues
during repeated testing
(not recommended)
2017)
semicircular canal
BPPV
- Hx compatible with BPPV
& Dix-Hallpike test elicits
horizontal/zero nystagmus
(Bhattacharyya et al., 2017; You et
al., 2019)
semicircular canal
BPPV
- Less common type

al., 2019)
semicircular canal
BPPV
- Affects the
horizontal/lateral
semicircular canal
al., 2019)
semicircular canal
BPPV
- Tested with the Supine
Head Roll Test/Pagnini-
McClure maneuver
al., 2019)
semicircular canal
BPPV
- No latency, responses
don’t fatigue & duration
may be > 60 secs
(Soloman, 2000; Steddin et al.,
1996)
semicircular canal
BPPV
- 2 types

semicircular canal
BPPV
- Geotropic
- Ageotropic/Apogeotropic

semicircular canal
BPPV
- Geotropic
- Ageotropic/Apogeotropic

b. Horizontal/Lateral semicircular
canal BPPV
- Geotropic:
- Nystagmus beats to the
ground (downbeat) when
head is rolled to pathological
or good side during Supine
Head Roll Test
b. Horizontal/Lateral semicircular
canal BPPV
- Apogeotropic:
- Nystagmus beats away
from the ground (upbeat)
when head is rolled to
pathological or good side
during Supine Head Roll Test
Clinically
Relevant
Anatomy
VESTIBULAR SYSTEM
(Part of inner ear)
- Monitors motion and
position of the head in
space
VESTIBULAR SYSTEM
(Part of inner ear)
- Monitors motion and
position of the head in
space
(Neil et al., 2008)
VESTIBULAR SYSTEM
(Part of inner ear)
- Detects angular and
linear acceleration
(Neil et al., 2008)

VESTIBULAR SYSTEM (Part of inner ear)
- 3 semicircular canals in
the inner ear detect
angular acceleration and
are positioned at near
right angles to each other.
(Neil et al., 2008)
VESTIBULAR SYSTEM (Part of inner ear)
- vestibular apparatus within each
ear so under normal circumstances,
the signals being sent from each
vestibular system to the brain
should match, confirming that the
head is indeed rotating to the right,
for example…
(Neil et al., 2008)
Etiology
/Causes
Displacement of
otoconia from the
maculae of the inner
ear into the fluid-filled
semicircular canals
(Shim et al., 2014)
Semicircular canals
sensitive to gravity
(Ogun et al., 2014)

changes in head
position can be a
trigger for BPPV
(Ogun et al., 2014)

Otoconia/otoliths
causes abnormal
(pathological) fluid
endolymph displacement
in the affected ear
(Shim et al., 2014)

Resultant mismatch in
signals coming from the right
and left vestibular systems
Sensation of Vertigo
(Shim et al., 2014)

Canalithiasis
Cupulolithiasis
(Shim et al., 2014)

Canalithiasis
Cupulolithiasis
(Shim et al., 2014)

Canalithiasis
- Otoconia in canals, short
duration since crystals settle
Cupulolithiasis
(Shim et al., 2014)

Canalithiasis
Cupulolithiasis
- Otoconia adhered to cupula, does
not resolve until head is moved out
of provocative position since
crystals stick to the cupula and
continue displacing endolymph
(Shim et al., 2014)
- idiopathic
- head injury
- aging: vestibular degeneration
- surgery due to prolonged
supine positioning and possible
trauma to the inner ear
(Lorne et al., 2003)

- idiopathic
- head injury

- idiopathic
- head injury

- idiopathic
- head injury

Other Risk Factors
Female gender: female to male ratio
is 3:1 (Gaur et al., 2015).
Hypertension (HTN)
Hyperlipidemia
Cerebrovascular disease
Menopause
Allergies
Migraine
(COPD)
(Chen et al., 2016)
Other Risk Factors
is 3:1 (Gaur et al., 2015).
Hypertension (HTN)
Hyperlipidemia
Menopause
Allergies
Migraine
(COPD)
(Chen et al., 2016)
Other Risk Factors
is 3:1 (Gaur et al., 2015).
Hypertension (HTN)
Hyperlipidemia
Menopause
Allergies
Migraine
(COPD)
(Chen et al., 2016)
Other Risk Factors
is 3:1 (Gaur et al., 2015).
Hypertension (HTN)
Hyperlipidemia
Menopause
Allergies
Migraine
(COPD)
(Chen et al., 2016)
Other Risk Factors
is 3:1 (Gaur et al., 2015).
Hypertension (HTN)
Hyperlipidemia
Menopause
Allergies
Migraine
(COPD)
(Chen et al., 2016)
Other Risk Factors
is 3:1 (Gaur et al., 2015).
Hypertension (HTN)
Hyperlipidemia
Menopause
Allergies
Migraine
(COPD)
(Chen et al., 2016)
Other Risk Factors
is 3:1 (Gaur et al., 2015).
Hypertension (HTN)
Hyperlipidemia
Menopause
Allergies
Migraine
(COPD)
(Chen et al., 2016)
Other Risk Factors
is 3:1 (Gaur et al., 2015).
Hypertension (HTN)
Hyperlipidemia
Menopause
Allergies
Migraine
(COPD)
(Chen et al., 2016)
Other Risk Factors
is 3:1 (Gaur et al., 2015).
Hypertension (HTN)
Hyperlipidemia
Menopause
Allergies
Migraine
(COPD)
(Chen et al., 2016)
Prevalence
- Dizziness: 5.6 million visits/year
- 14-17% of said patients
diagnosed BPPV
(Gaur et al., 2015)

- Dizziness: 5.6 million visits/year
- 14-17% of said patients
diagnosed BPPV
(Gaur et al., 2015)

- Female to male ratio is 3:1
(Gaur et al., 2015)

- Recurrence rate at one year
post initial bout of BPPV: 15%
- At 5 years the recurrence
rate is 37-50%
(Bhattacharyya et al, 2008)
- Recurrence rate at one year
post initial bout of BPPV: 15%
- At 5 years the recurrence
rate is 37-50%
(Bhattacharyya et al, 2008)
A clinical diagnosis of
anxiety are 2.7 times more
likely to develop BPPV.
(American Hearing Research
Foundation, 2022)
Lifetime prevalence
is 2.4 %
(Gaur et al., 2015)

A prevalence hospital-based study of
all patients with the diagnosis of
benign paroxysmal positional vertigo in
ear, nose, and throat department of
Ekiti state university teaching hospital,
Ado Ekiti, Nigeria.
(Waheed et al., 2019)
BPPV had a peak prevalence
of 37% at age group (41-50)
years for all the studied age
groups.
(Waheed et al., 2019)
Clinical
Presentation
 Symptoms:
• Vertigo: Spinning sensation
• Short duration (Paroxysmal): Lasts
only seconds to minutes
• Positional in onset: only induced by a
change in position
• Nausea
• Visual disturbance
• Pre-Syncope (feeling faint) or Syncope
(fainting)
• Vomiting is uncommon, but possible.
• Loss of balance
(Balatsouras et al., 2011)
 Symptoms:
change in position
• Nausea
(fainting)
• Loss of balance
 Symptoms:
change in position
• Nausea
(fainting)
• Loss of balance
 Symptoms:
change in position
• Nausea
(fainting)
• Loss of balance
 Symptoms:
change in position
• Nausea
(fainting)
• Loss of balance
 Symptoms:
change in position
• Nausea
(fainting)
• Loss of balance
 Symptoms:
change in position
• Nausea
(fainting)
• Loss of balance
 Symptoms:
change in position
• Nausea
(fainting)
• Loss of balance
 Symptoms:
change in position
• Nausea
(fainting)
• Loss of balance
 Signs:
• Rotatory (torsional)
Nystagmus
• Geotropic Nystagmus
• Apogeotropic
Nystagmus
 Signs:
Nystagmus
• Apogeotropic
Nystagmus
 Signs:
Nystagmus
• Apogeotropic
Nystagmus
 Signs:
Nystagmus
• Apogeotropic
Nystagmus
 Signs:
Nystagmus
• Apogeotropic
Nystagmus
Diagnostic
Procedures
Diagnosed and
treated through
simple clinic-based
procedures
(Coelho et al., 2020)
In-depth subjective
screening, followed by
physical investigations and
diagnostic maneuvers to
confirm BPPV.

PATIENT Hx
i. Type of dizziness and vertigo
ii. Duration of dizziness and
vertigo
iii. Precipitating and exacerbating
factors
iv. Accompanying symptoms
PATIENT Hx
vertigo
factors
PATIENT Hx
vertigo
factors
PATIENT Hx
vertigo
factors
PATIENT Hx
vertigo
factors
According to average
patient:
i. Rolled over in bed
ii. Extended neck to look
up
iii. Bent forward
(Strupp & Brandt, 2008)
patient:
up
iii. Bent forward
patient:
up
iii. Bent forward
patient:
up
iii. Bent forward
Physical screening:

Physical screening:
- Dix-Hallpike Test
- Supine Head Roll Test
(Parnes et al., 2003)

Physical screening:
- Dix-Hallpike Test
- Supine Head Roll Test

Physical screening:
- Dix-Hallpike Test
Used to assess Posterior
Semicircular Canal BPPV

Physical screening:
- Head Roll Supine Test
Used to assess
Horizontal/Lateral
Semicircular Canal BPPV

BPPV Nystagmus Xcteristics:
Positional: the nystagmus occurs only in
certain positions
Latency of onsent: there is a 5-10 second
delay prior to onset of nystagmus
Nystagmus lasts for 5-30 seconds
Visual fixation does not suppress
nystagmus due to BPPV

certain positions

certain positions

certain positions

certain positions

Both a rotatory and upbeat vertical
components are present (torsional)
Repeated Dix-Hallpike maneuvers cause the
nystagmus to fatigue or disappear temporarily
If nystagmus and vertigo are sustained,
cupulolithiasis or a potentially more central
cause of vertigo should be considered. Patient
history and other neurological tests can help
to rule out a more serious central cause.



Medical
Management
BENIGN
DIAGNOSIS

Resolve occasionally
with no intervention
(Steenerson & Cronin, 1996)

Singular Nerve
Neurectomy and
Posterior Canal
Occlusion
(Steenerson & Cronin, 1996)

No medications
directly treat
BPPV
(Brain & Spine Foundation, 2021)
Antivert, Meclizine and
vestibular suppressants
can be prescribed to
treat symptoms
(Brain & Spine Foundation, 2021)

Physiotherapy
Management
EPLEY
GUFONI
SEMONT
References

BPPV

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PHYSIOTHERAPY MANAGEMENT OF

BENIGN PAROXYSMAL POSITIONAL

(Shim et al., 2014)

(Shim et al., 2014)

(Shim et al., 2014)

(Shim et al., 2014)

(Shim et al., 2014)

(Shim et al., 2014)

(Health Direct, 2022)

(Health Direct, 2022)

(Health Direct, 2022)

(Stanton & Freeman, 2021)

(Stanton & Freeman, 2021)

(Bhattacharyya et al., 2017)

(Bhattacharyya et al., 2017)

(Soloman, 2000; Bhattacharyya et

(Soloman, 2000; Bhattacharyya et al., 2017; Imai et al.,

(Soloman, 2000; Bhattacharyya et

(Bhattacharyya et al., 2017; You et

(Bhattacharyya et al., 2017)

(Bhattacharyya et al., 2017)

(Bhattacharyya et al., 2017)

(Neil et al., 2008)

(Ogun et al., 2014)

(Ogun et al., 2014)

(Shim et al., 2014)

(Shim et al., 2014)

(Shim et al., 2014)

(Shim et al., 2014)

(Shim et al., 2014)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Gaur et al., 2015)

(Gaur et al., 2015)

(Gaur et al., 2015)

(Gaur et al., 2015)

(Coelho et al., 2020)

(Coelho et al., 2020)

(Parnes et al., 2003)

(Parnes et al., 2003)

(Parnes et al., 2003)

(Parnes et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Lorne et al., 2003)

(Steenerson & Cronin, 1996)

(Steenerson & Cronin, 1996)

(Brain & Spine Foundation, 2021)

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