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BPPV is a common cause of dizziness. About 20% of all dizziness is due to BPPV. The
older you are, the more likely it is that your dizziness is due to BPPV, as about 50% of
all dizziness in older people is due to BPPV.
The symptoms of BPPV include dizziness or vertigo, lightheadedness, imbalance, and
nausea. Activities which bring on symptoms will vary among persons, but symptoms are
almost always precipitated by a change of position of the head with respect to gravity.
Getting out of bed or rolling over in bed are common "problem" motions . Because
people with BPPV often feel dizzy and unsteady when they tip their heads back to look
up, sometimes BPPV is called "top shelf vertigo." Women with BPPV may find that the
use of shampoo bowls in beauty parlors brings on symptoms. An intermittent pattern is
common. BPPV may be present for a few weeks, then stop, then come back again.
WHAT CAUSES BPPV?
The most common cause of BPPV in people under age 50 is head injury . There is also
an association with migraine (Ishiyama et al, 2000). In older people, the most common
cause is degeneration of the vestibular system of the inner ear. BPPV becomes much
more common with advancing age. In half of all cases, BPPV is called "idiopathic," which
means it occurs for no known reason. Viruses affecting the ear such as those causing
vestibular neuritis , minor strokes such as those involving anterior inferior cerebellar
artery (AICA) syndrome, and Meniere's disease are significant but unusual causes.
HOW IS THE DIAGNOSIS OF BPPV MADE?
Your physician can make the diagnosis based on your history, findings on physical
examination, and the results of vestibular and auditory tests. Often, the diagnosis can
be made with history and physical examination. Most other conditions that have
positional dizziness get worse on standing rather than lying down (e.g. orthostatic
hypotension). It is possible but rather uncommon to have BPPV in both ears (bilateral
HOW MIGHT BPPV AFFECT MY LIFE?
Certain modifications in your daily activities may be necessary to cope with your
dizziness. Use two or more pillows at night. Avoid sleeping on the "bad" side. In the
morning, get up slowly and sit on the edge of the bed for a minute. Avoid bending
down to pick up things, and extending the head, such as to get something out of a
cabinet. Be careful when at the dentist's office, the beauty parlor when lying back
having ones hair washed, when participating in sports activities and when you are lying
flat on your back.
HOW IS BPPV TREATED?
BPPV has often been described as "self-limiting" because symptoms often subside or
disappear within six months of onset. Symptoms tend to wax and wane. Motion
sickness medications are sometimes helpful in controlling the nausea associated with
BPPV but are otherwise rarely beneficial. However, various kinds of physical maneuvers
and exercises have proved effective. Three varieties of conservative treatment, which
involve exercises, and a treatment that involves surgery are described in the next
OFFICE TREATMENT OF BPPV: The Epley Maneuver
The most effective treatment of BPPV is performed in the doctor's office. The treatment
is very effective, with roughly an 80% cure rate, according to a study by Herdman and
others (1993). If your doctor is unfamiliar with these treatments, call our office for an
The maneuver, named after its inventors, is intended to move debris or "ear rocks" out
of the sensitive part of the ear (posterior canal) to a less sensitive location. The
maneuver takes about 15 minutes or less to complete. The recurrence rate for BPPV
after these maneuvers is about 30 percent at one year, and in some instances a
second treatment may be necessary.
After either of these maneuvers, you should be prepared to follow the instructions
below, which are aimed at reducing the chance that debris might fall back into the
sensitive back part of the ear.
INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS:
WHAT IF THE MANEUVERS DON'T WORK?
These maneuvers are effective in about 80% of patients with BPPV. If you are among
the other 20 percent, your doctor may wish you to proceed with the Brandt-Daroff
exercises, as described below. If a maneuver works but symptoms recur or the
response is only partial, another trial of the maneuver might be advised. The
"habituation" exercises are also sometimes useful in the situation where all other
maneuvers have been tried -- in essence these consist of a more intense and
prolonged series of positional exercises.
HOME TREATMENT OF BPPV: BRANDT-DAROFF EXERCISES
The Brandt-Daroff Exercises are a method of treating BPPV,
usually used when the office treatment fails. They succeed
in 95% of cases but are more arduous than the office treat-
ments. These exercises are performed in three sets per day
for two weeks. In each set, one performs the maneuver as
shown five times.
1 repetition= maneuver done to each side in turn ( 2 mins)
Suggested Schedule for Brandt-Daroff exercises:
Start sitting upright (position 1). Then move into the side-
lying position (position 2), with the head angled upward
about halfway. An easy way to remember this is to imagine
someone standing about 6 feet in front of you, and just keep looking at their head at
all times. Stay in the side-lying position for 30 seconds, or until the dizziness subsides
if this is longer, then go back to the sitting position (position 3). Stay there for 30
seconds, and then go to the opposite side (position 4) and follow the same routine..
These exercises should be performed for two weeks, three times per day, or for three
weeks, twice per day. This adds up to 52 sets in total. In most persons, complete relief
from symptoms is obtained after 30 sets, or about 10 days. In approximately 30
percent of patients, BPPV will recur within one year. If BPPV recurs, you may wish to add
one 10-minute exercise to your daily routine.
The home-Epley maneuver can also be used very successfully to treat BPPV. They also
succeed in about 95% of cases within one week. These are done in one set/day, usually
in the evening. Compared to the Brandt-Daroff exercises, a disadvantage of the
home-Epley is that one must know which is the "bad" side.
THE CHIROPRACTIC LIFESTYLE
Chiropractors are experts in the care of the bones, nerves, muscles and connective
tissues that make up about 60% of your body. All of the joints in your body are part of
this musculo-skeletal system and its optimal function is necessary for overall good
health. Ask your Doctor of Chiropractic for more information about a care program that
may include specific spinal adjustments, exercise recommendations, nutritional advice
or other conservative methods of care based on your health history, age, current
condition and lifestyle.
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|1. Wait for 10 minutes after the maneuver is performed before going
home. This is to avoid "quick spins," or brief bursts of vertigo as
debris repositions itself immediately after the maneuver.
2. Sleep semi-recumbent for the next two nights. This means sleep
with your head halfway between being flat and upright (a 45 degree
angle). This is most easily done by using a recliner chair or by using
pillows arranged on a couch. During the day, try to keep your head
vertical. You must not go to the hairdresser or dentist. No exercise
which requires head movement. When men shave under their chins,
they should bend their bodies forward in order to keep their head
vertical. If eyedrops are required, try to put them in without tilting the
head back. Shampoo only under the shower.
3. For at least one week, avoid provoking head positions that might
bring BPPV on again.
Use two pillows when you sleep. Avoid sleeping on the "bad" side.
Don't turn your head far up or far down.
Be careful to avoid head-extended position, in which you are lying on
your back, especially with your head turned towards the affected side.
This means be cautious at the beauty parlor, dentist's office, and while
undergoing minor surgery. Try to stay as upright as possible.
Exercises for low-back pain should be stopped for a week. No "sit-ups"
should be done for at least one week. Also avoid far head-forward
positions such as might occur in certain exercises (i.e. touching the
toes). Do not start doing the Brandt-Daroff exercises immediately or 2
days after the Epley or Semont maneuver, unless specifically instructed
otherwise by your health care provider.
4. At one week after treatment, put yourself in the position that usually
makes you dizzy. Position yourself cautiously and under conditions in
which you can't fall or hurt yourself. Let your doctor know how you did.