Why am I dizzy? Is it BPPV?

Someone recently asked me about their elderly mother doing maneuvers for the home treatment of BPPV.  Since she is elderly she apparently had difficulty moving her head back far enough to complete the standard maneuver.    

The good news about home treatment is that the Epley Maneuver can be conducted at home with some help.  This is much more effective than previous maneuvers such as the Brant Daroff exercises.  The hope is that fewer maneuvers need be conducted to successfully treat the condition. 

However, some people should not perform the maneuver.  This includes, amongst others, people with neck injury, limitation of their neck range of motion, a history of stroke/TIA due to vertebro-basilar insufficiency and other health conditions as advised by their doctor.

Certainly home maneuvers are effective but they should not be conducted alone or by people who have difficulty or other medical conditions which put them at risk. Home maneuvers should always be conducted on the floor to prevent falls and in the presence of another person for assistance if needed.  When in doubt see your doctor.

I was recently asked: “Has any BPPV patient managed to make their condition worse with a bungled treatment?”

The answer is not particularly straight forward.  Any treatment of BPPV has the potential to convert to something called Horizontal canal BPPV. The most common type of BPPV is Posterior canal BPPV. 

The estimated rate of this complication of treatment of BPPV is about 5%. You run this risk every time you roll over in bed but in particular during a repositioning maneuver. The good news is that horizontal BPPV, while more intense (if you can believe that) it is often short lived and goes away by itself in nearly all cases.

Home treatment of BPPV has no higher risk of this conversion than office maneuvers. The only benefit of the in office treatment is that there is someone there to comfort you.  I also suggest that you never do the maneuver alone even if you are doing it at home. You just never know if you need help if you vomit or feel nauseous.

Following a treatment maneuver for BPPV many practitioners recommend staying upright for 48 hours.  This recommendation makes some empiric sense.  The idea behind it is to allow the particles, disturbed like snow in a snow globe, to settle before exposing the opening of the posterior canal by lying down.

In the attached image you can see the particles and the opening to the canal, at the top.  However, these precautions were never proven.  In fact, a number of researchers have demonstrated that restrictions do not interfere in the results of the Epley canalith repositioning maneuver. We think that this is because the disturbed particles, like snow flakes, don’t cause problems until they form clumps.  Unfortunately, there is no way to keep the flakes from finding there way back into the posterior canal everytime you “shake the snow globe” by lying down.  Eventually clumps will form again.  This is why BPPV is recurrent.

Many people who do try to complete the post maneuver precautions find that they loose two nights of sleep and get a sore neck. I am not sure it is worth it when there is no evidence for it and plenty against.  Below are three of the published articles on how and why the post maneuver precuations are of limited value.

•  Simoceli L, Bittar RS, Greters ME. Posture restrictions do not interfere in the results of canalith repositioning maneuver.  Braz J Otorhinolaryngol. 2005 Jan-Feb;71(1):55-9. Epub 2006 Jan 2.[PubMed]
• Nuti D, Nati C, Passali D. Treatment of benign paroxysmal positional vertigo: no need for postmaneuver restrictions. Otolaryngol Head Neck Surg 2000;122:440-4. [PubMed]
• Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol 1996;25:121-5. [PubMed]

Vertigo and dizziness are very distressing problems.  Some say that nausea is worse than pain.  At least pain makes some physiologic sense.

Vestibular diseases are problematic in that they are so poorly understood. Many patients  end up vague diagnosis such as recurrent vestibulopathy.  Medical science has just not reached a point where we can diagnose every kind of problem.  Further, even those conditions which we can diagnose may not have effective treatments.  Tinnitus is a good example of a difficult to treat condition.  Sure we can tell you what it is, but get used to it, because many times we don’t know how to effectively treat it.  Mind you that is not for a lack of trying.  Some conditions like BPPV are quite easy to treat if you get the Epley Maneuver or other particle repositioning.  However, there are many other causes of vertigo which may not be so easy to treat.

Even if doctors can’t give you a good diagnosis for your condition or an effective treatment there is still hope.  The hope that despite your problem you can overcome it by understanding it and developing coping skills.

There are a number of resources on line which you might find useful in understanding the diseases of the vestibular system

Timothy C. Hain has a great website:
http://www.tchain.com/otoneurology/default.htm or http://www.dizziness-and-balance.com/index.html

Also
http://www.vestibular.org/vestibular-disorders/specific-disorders/bppv.php

There are also a number of very good “on line” support groups for people with similar problems who may be able to offer advice and support  www.thedizzylounge.com or www.dizzytimes.com

Don’t despair – there are new treatments on the horizon every day.

People often ask what it was that made them get BPPV.  For many there is never really a satisfactory answer.  However we do know some factors which may pre-dispose a person to getting vertigo due to BPPV.  Any condition which damages the inner ear seems to be associated with BPPV.  This ranges from trauma, to infections to the ever present condition – old age.

To put some specifics on what the etiology or causes of BPPV are:

• About 70% of people have age related BPPV
• About 15% of people have BPPV related to a trauma such as a car accident
• About 15% of people have BPPV following a viral infection which may include labyrinthitis (which presents as two weeks of vertigo followed by BPPV) 
• There may also be a few percent which occurs with Meniere’s or other inner ear conditions which causes damage to the ear resulting in loose crystals and BPPV.

BPPV is a spectrum of etiologies and presentations which are caused by loose otoconia or inner ear crystals. Most people have similar BPPV symptoms but this is not always the case. It is important that everyone be evaluated by their physician and other causes of dizziness be ruled out.