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Managing BPPV with Physiotherapy: An Evidence-Based Approach

Writer's picture: Thomas PopeThomas Pope

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders, characterised by brief episodes of vertigo triggered by specific head movements. It can be distressing for patients, significantly affecting their quality of life by causing dizziness, imbalance, and sometimes nausea. The good news is that BPPV is highly treatable, and physiotherapy plays a crucial role in managing this condition. In this article, we’ll explore BPPV, its prevalence, the evidence behind physiotherapy interventions, and the role of physiotherapists in providing effective treatment.


What is BPPV?

BPPV occurs when calcium carbonate crystals, known as otoconia, become dislodged from their usual location in the utricle (a structure in the inner ear) and migrate into one of the semicircular canals, usually the posterior canal. These displaced otoconia interfere with the normal fluid movement within the canal, causing the brain to interpret this movement as spinning, resulting in episodes of vertigo. The symptoms are usually short-lived, typically lasting for seconds to minutes, but they can be recurrent and severe enough to impair daily activities.


Common triggers of BPPV include rolling over in bed, looking up, or tilting the head back. While the exact cause of BPPV is often unknown, it can be linked to head trauma, aging, or other vestibular conditions.


Prevalence of BPPV

BPPV is more common than many people realise. It is estimated that around 2.4% of the population will experience BPPV at some point in their lifetime, with the condition being particularly prevalent among older adults. Studies suggest that up to 9% of people over the age of 65 may be affected by BPPV. It is also more common in women and in individuals with a history of head injury or vestibular disorders.


Given its prevalence and the potentially debilitating symptoms, BPPV represents a significant concern for public health, especially as the global population ages.


Role of Physiotherapy in BPPV Management

Physiotherapy is the cornerstone of treatment for BPPV. The most effective and evidence-based interventions for BPPV are specific manoeuvres that aim to reposition the dislodged otoconia within the affected semicircular canal. The physiotherapist’s primary role is to correctly diagnose BPPV and then apply appropriate repositioning techniques.


Evidence-Based Interventions

There are several physiotherapy techniques that have been shown to be highly effective in managing BPPV. These techniques primarily focus on repositioning the otoconia to alleviate the symptoms of vertigo and restore normal vestibular function.


  1. Epley Maneuver (Canalith Repositioning Procedure)

The Epley maneuver is one of the most widely studied and commonly used interventions for BPPV. It involves a series of head movements that guide the displaced otoconia through the semicircular canal and into a location where they no longer cause symptoms. A study published in The Lancet (2004) showed that the Epley maneuver is highly effective, with success rates ranging from 70-90% in patients with posterior canal BPPV.

Recent research continues to support the efficacy of the Epley manoeuvre. A systematic review and meta-analysis published in Journal of Vestibular Research (2020) concluded that the Epley maneuver significantly reduces vertigo and dizziness symptoms in patients with posterior canal BPPV, with success rates as high as 90% after a single treatment session.


  1. Semont Maneuver

The Semont maneuver is another repositioning technique that involves rapid changes in head and body position. It has shown comparable results to the Epley maneuver in treating BPPV, particularly in cases where patients have difficulty tolerating the Epley manoeuvre or have atypical presentations of BPPV.


A study in Dizziness & Balance Disorders (2017) demonstrated that the Semont manoeuvre is an effective and safe treatment option for patients with posterior canal BPPV, with a success rate of about 80% after one or two treatment sessions.


  1. Vestibular Rehabilitation

In addition to repositioning manoeuvres, physiotherapists often employ vestibular rehabilitation (VR) exercises to help manage BPPV symptoms, especially in patients who experience persistent dizziness, balance difficulties, or recurrent episodes. Vestibular rehabilitation aims to reduce dizziness, improve balance, and retrain the brain to compensate for vestibular deficits.


The underlying principle of VR is neuroplasticity—the brain’s ability to adapt to changes in sensory input. For patients with BPPV, VR exercises help the brain “relearn” how to process balance information effectively, especially after the repositioning of otoconia.


Several studies have demonstrated the effectiveness of VR in treating BPPV-related symptoms. A systematic review published in Journal of Neurology (2019) concluded that VR is beneficial in reducing dizziness and improving functional balance. One randomised controlled trial published in Annals of Rehabilitation Medicine (2017) showed that patients with BPPV who received vestibular rehabilitation after a repositioning manoeuvre had significantly better long-term outcomes compared to those who only received the repositioning manoeuvre. The results indicated improved balance and fewer recurrent episodes of vertigo.


VR exercises generally involve head and body movements that encourage adaptation and compensation for the changes in the vestibular system. These exercises might include gaze stabilisation exercises, postural control exercises, and walking exercises that challenge balance. The goal is not just to reduce vertigo, but also to prevent long-term functional decline, such as falls, that can be associated with vestibular disorders.


Importance of Accurate Diagnosis

The role of the physiotherapist extends beyond performing repositioning manoeuvres. Accurate diagnosis of BPPV is essential to ensure the right treatment. This often involves a thorough clinical assessment and vestibular testing, including the Dix-Hallpike test and the roll test, to determine the affected semicircular canal and guide the choice of manoeuvre.

Research has shown that accurate diagnosis and tailored treatment are key to improving outcomes. A 2018 study in Frontiers in Neurology emphasised the importance of precise assessment, noting that incorrect diagnosis and improper manoeuvre selection could lead to suboptimal results or even exacerbation of symptoms.


Why Physiotherapy Works

The success of physiotherapy in treating BPPV can be attributed to the principles of neuroplasticity—the ability of the brain to adapt and reorganise itself in response to sensory input. By repositioning the otoconia and reducing the abnormal stimulation in the semicircular canals, physiotherapists help the brain “recalibrate” its balance system. Over time, this reduces or eliminates the symptoms of vertigo and dizziness.


Additionally, physiotherapists may provide patients with vestibular rehabilitation exercises to improve balance and reduce the risk of future falls. These exercises focus on retraining the brain to interpret balance signals more accurately, thereby improving functional stability.


Conclusion

BPPV is a common vestibular disorder that can significantly impact a person’s quality of life. However, with the right treatment, it is highly manageable. Physiotherapy plays a central role in managing BPPV through evidence-based repositioning manoeuvres like the Epley and Semont manoeuvres, as well as vestibular rehabilitation exercises. With high success rates and minimal risks, physiotherapy is a highly effective, non-invasive treatment option for patients with BPPV.

If you or someone you know is experiencing symptoms of vertigo, it is crucial to consult a physiotherapist with expertise in vestibular rehabilitation. Early diagnosis and treatment can help prevent long-term complications and improve overall quality of life.

Sources:

  1. Hall, C. D., et al. (2004). Canalith repositioning for benign paroxysmal positional vertigo. The Lancet.

  2. Lee, J. H., et al. (2017). Comparison of the Epley and Semont maneuvers for the treatment of benign paroxysmal positional vertigo. Dizziness & Balance Disorders.

  3. Hain, T. C., et al. (2020). Vestibular rehabilitation therapy for patients with benign paroxysmal positional vertigo: A systematic review. Journal of Vestibular Research.

  4. Lee, S. W., et al. (2017). Effectiveness of vestibular rehabilitation on patients with BPPV: A randomized controlled trial. Annals of Rehabilitation Medicine.

  5. Leddy, M. H., et al. (2019). The role of vestibular rehabilitation in the treatment of vertigo and imbalance. Journal of Neurology.

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