Benign paroxysmal positional vertigo, or BPPV, is a mechanical issue in the inner ear. It occurs when some of the calcium carbonate crystals (otoconia) that are normally embedded in gel at the utricle become dislodged and migrate to at least one of those 3 fluid-filled semicircular canals, where they are not supposed to be. When enough of these particles accumulate in one of the canals they interfere with the normal fluid motion that these canals utilize to sense head motion, causing the inner ear to send false signals to the mind.
Fluid in the semi-circular canals doesn’t normally react to gravity. However, the crystals do proceed with gravity, thereby shifting the fluid when it normally would be still. When the fluid moves, nerve endings in the canal are eager and send a message to the brain the mind is moving, even though it is not. This false information doesn’t match what another ear is sensing, together with what the eyes are seeing, or with what the joints and muscles are doing, and also this mismatched information is perceived by the brain as a turning sensation, or vertigo, which generally lasts less than one minute. Between vertigo spells some people today feel symptom-free, while some feel a mild sense of imbalance or disequilibrium.
A healthcare professional will execute a collection of tests and evaluations in order to properly diagnose the individual’s BPPV. Regular medical imaging (e.g. an MRI) is not helpful in diagnosing BPPV, because it doesn’t show the crystals which have moved to the semi-circular canals. But when someone with BPPV has their own head moved into a position that produces the dislodged crystals move within a tube, the error signals cause the eyes to move in a very specific pattern, called”nystagmus”.
The nystagmus will possess distinct characteristics that let a trained practitioner to identify which ear the crystals that are displaced are in, and then canal(s) they have moved into. Tests such as the Dix-Hallpike or Roll Tests involve moving the head into specific orientations, allowing gravity to move the dislodged crystals and activate the vertigo while the professional watches for the tell-tale eye movements, or nystagmus. To execute the Dix-Hallpike test, a healthcare professional will ask the patient to sit on the test table with their legs stretched out. They will then turn the head 45 degrees to one side, which contrasts the right posterior semicircular canal with the sagittal plane of the body, then they are going to allow the patient to lie back quickly, while the eyes are open, so that their head hangs slightly over the edge of the desk.
When the health care provider has finished the diagnosis, then they can perform the appropriate treatment maneuver. The maneuvers make use of gravity to guide the crystals back to the room where they are supposed to be via a very specific series of head movements, commonly referred to as Repositioning Maneuvers. Repositioning maneuvers are highly effective in treating BPPV, inexpensive, and easy to apply.
Dr. Alex Jimenez’s Insights
While the use of surgical interventions as well as that of drugs and/or medications are occasionally recommended to relieve the symptoms associated with benign paroxysmal positional vertigo, or BPPV, they do not treat the underlying health issue. Repositioning maneuvers, like the ones demonstrated below, are considered to be safe yet effective treatment options for BPPV. There is good evidence to support the treatment of BPPV with the Epley maneuver. Although less amounts of research studies have been conducted on other repositioning maneuvers, outcome measures of a variety of patients with BPPV have benefitted from the other treatment options for benign paroxysmal positional vertigo.
Considering that the therapeutic efficacy among maneuvers for every canal is comparable, the option of treatment is generally predicated on clinician preference, complexity of their maneuvers themselves, therapy response to certain maneuvers, as well as musculoskeletal considerations, such as arthritic changes and range of motion of the cervical spine. Below, many repositioning maneuvers are demonstrated, for instance, deep mind hanging maneuver, the Lempert (BBQ) maneuver and the Epley maneuver.
The deep head hanging maneuver is a repositioning maneuver which is used for one of the least common places where BPPV occurs, the superior semi-circular canal, amounting to only about 2 percent of most benign paroxysmal positional vertigo instances. However, the advantage of deep head hanging maneuvers is that they may be effectively performed without knowledge of the side involved. It consists of three steps with four position changes at intervals of approximately 30 seconds.
The deep head hanging maneuver is performed with the patient at the long-sitting position, while the head is brought to a minimum of 30° below the horizontal with the head straight up. When the nystagmus induced by this measure is finished, the head is brought up rapidly to touch the chest while the patient remains supine, and after 30 seconds, the individual has been brought back to a seated position with head flexion maintained. Finally, the patient will be brought back to a neutral head position.
The Lempert maneuver, also referred to as the Barbeque maneuver or the Roll maneuver, is a repositioning maneuver commonly utilized to help treat canilithiasis of the horizontal and lateral canal. It might occur as a complication of posterior canal BPPV treatment repositioning maneuvers. The side with the most notable horizontal nystagmus is assumed to be the affected side.
To perform the Lempert maneuver, the patient should lie supine on the exam table, using the affected ear facing down. Afterward, the healthcare professional will quickly turn the head 90° towards the unaffected side, facing up, waiting 15-20 minutes between each head turn. The medical professional will subsequently turn the head 90° so the affected ear is currently facing up. The next step includes having the individual tuck their arms to their torso, in order to allow the doctor to roll the patient to a more moderate position with their head down. The individual must be turned on their side since the physician rolls their head 90° (returning them to their original position, with the affected ear facing down ). At length, the medical professional should place the patient so that they are face up and bring them into a sitting posture.
Treatment with the Lempert maneuver is efficient approximately 75% of the moment, however, the effectiveness can vary from individual to individual. It is important to keep in mind that longer periods of time between head turns may provoke nausea. This sort of repositioning maneuver shouldn’t be done on patients in which it isn’t safe to move their mind, including in the case of cervical spine injuries.
Epley Maneuver for BPPV
The most common repositioning maneuver for the treatment of benign paroxysmal positional vertigo, or BPPV, is known as the Epley maneuver. The Epley maneuver, occasionally referred to as the canalith repositioning maneuver, is a process which involves a series of head movements, normally performed by a healthcare professional who’s experienced and qualified in the treatment of vestibular disorders, so as to relieve the symptoms associated with BPPV, including dizziness.
The Epley maneuver is performed by placing the patient’s mind at an angle in where gravity can help alleviate the symptoms. Tilting the mind can move the crystals out of the semicircular canals of the inner ear. This means that they will quit displacing the fluid, relieving the dizziness and nausea they may have been causing. In this manner, the Epley maneuver alleviates the symptoms of BPPV. But, it may have to be repeated more than once, as occasionally, some head movements can once again displace the small crystals of the internal ear, once they had been repositions after the first treatment.
Research studies have shown that the Epley maneuver is a safe and effective treatment for the specific vertigo disorder, offering both long-term and immediate relief. The Epley maneuver, named after Dr. John Epley, has been named the canalith repositioning maneuver because it helps to reposition the small crystals at a person’s inner ear, which might be causing the sensation of dizziness.
Repositioning these tiny crystals called otoconia helps to ease BPPV symptoms. There are two types of BPPV: one where the loose crystals can move freely in the fluid of the canal (canalithiasis), and, more rarely, one where the crystals are thought to be ‘hung up’ on the bundle of nerves that sense the fluid movement (cupulolithiasis). It is important to make this distinction, as each repositioning maneuver may affect each variant differently. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
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