Benign Paroxysmal Positional Vertigo
Maintaining physical balance is essential in our everyday. From the time we get up in the morning, to when we go to bed, we are constantly sending and receiving signals which our brain interprets to unconsciously position our body for the maintenance of balance in everyday activities.
Balance is achieved by different systems in the body being stimulated and providing feedback to the brain. Our body has three main regulatory systems for balance:
- Vision – We use vision as a tool to provide feedback to the brain about where we are in relation to other objects and judge distances. We can use this information to adjust our body accordingly.
- Proprioception – Proprioception is the body’s awareness of its position in space. The brain gets this information from the muscles and tendons. Without this sense, you would be unable to do something as simple as touch your nose – you would be unaware where it is in relation to your hand.
- Vestibular function – This is the system we will delve into the most, it is the balance system of the inner ear. We will go into this system in more detail throughout this article.
BPPV
Benign Paroxysmal Positional Vertigo – known mostly as BPPV and colloquially as ‘ear rocks’ – is a dysfunction of the inner ear leading to feelings of vertigo and nausea in certain positions. Also known as postural vertigo, BPPV’s effects depend on which ear is affected, though on rare occasions it can be bilateral. Most of the time, BPPV is idiopathic, meaning it has no known cause, but can result from a head trauma – which is the majority of the bilateral cases.
Symptoms can include:
- Vertigo
- Dizziness
- Nausea
- Tinnitus (ringing in the ears)
- Nystagmus (eye flickering)
- Light-headedness
- Imbalance
The inner ear is responsible for our vestibular function. It is comprised of three fluid filled semi-circular canals, all oriented slightly differently.
The vestibular system detects changes in head position by monitoring angular and linear acceleration within the semi-circular canals by detecting the movement of the fluid via hair cells.
In BPPV cases, free-floating debris, called otoconia, are trapped in one of the semi-circular canals. These ‘ear rocks’ cause drag in the fluid during head movement, the drag consequently results in this feeling of vertigo as the hair cells are stimulated past the normal time in which the fluid would have settled. After the otoconia settles, the feeling of vertigo ceases, which means these attacks of vertigo usually last less than 30 seconds, until the afflicted individual moves further and causes it to begin all over again.
Think of it as similar to when you get dizzy spinning in tight circles – the hair cells continue to be stimulated in the opposite direction when you stop spinning as the fluid movement slows down. Your brain interprets this as spinning backward, causing you to get dizzy. The otoconia cause drag in the inner ear fluid and stimulates a similar sensation.
Differential diagnosis
Other conditions can cause similar symptoms to BPPV, it can be confused with:
- Meniere’s Disease
- Progressive disease affecting the inner ear causing vertigo, deafness, and tinnitus. Main difference is that is not dependant on position.
- Inner ear concussion
- Can include similar symptoms to BPPV, always the result of head trauma.
- Alcohol intoxication
- Alcohol has been shown cause a part of the inner ear to become lighter than the surrounding fluid, leading to feelings of vertigo.
- Labyrinthitis
- Inflammation of the vestibular nerve, which is the nerve connecting the inner ear to the brain. Usually a result of a viral infection.
- Vertebral artery insufficiency
- Insufficient blood supply in the vertebral artery caused by blockage. Can cause similar symptoms to BPPV, but in addition can cause upper limb paraesthesia.
- Orthostatic hypotension
- Postural low blood pressure. Symptoms usually when standing up from sitting or lying.
Diagnosis
The most stringently studied method for diagnosis is called the Dix-Hallpike test. The purpose of this test is to disturb the otoconia by moving the head from vertical to horizontal, and turning the head to the affected side. The patient will report their symptoms and the practitioner will look into the patients’ eyes to detect rapid eye movements known as nystagmus.
Treatment
BPPV usually lasts a few months, and can spontaneously resolve, or may need outside intervention. The most acknowledged treatment method is the Epley manoeuvre, the start of which is the same as the Dix-Hallpike. Once the dizziness has abated from the test, the head is turned 90 degrees to the unaffected side and held there. The purpose of this is to hopefully shift the otoconia out of the canal, so it no longer has an effect on the fluid. This manoeuvre may need to be performed several times over several treatment sessions.
Good vestibular function is essential if you want to reach your potential in your sport, as most sport require change of direction, change in body position, and change in height at some stage of play.
Take tennis for example:
To get a ball hit to the side of the tennis player, they must quickly move to the side, rotate their body in preparation for the swing, and change level if they have to crouch slightly. All of which will be very difficult to do, and impossible to do well, if the tennis player has impaired vestibular function.
If you are having problems with your balance, make sure you see a qualified practitioner for proper diagnosis and treatment such as the sports medicine specialists here at Absolute.
Written by Melbourne CBD Physiotherapist Kristin Cameron.
References
Choi M.S., Shin S.O., Yeon J.Y., Choi, Y.S., Kim K., and Park S.K. (2013). Clinical Characteristics of Labyrinthine Concussion. Korean Journal of Audiology. 17(1); 13-17.
Wagner M., Kitzerow E., Taitel A. (1963). Vertebral Artery Insufficiency. Arch Surg. 87(6); 885-886.
Parnes L.S., Agrawal S.K., and Atlas J. (2003). Diagnosis and treatment of benign paroxysmal positional vertigo (BPPV). Canadian Medical Association Journal. 169(7); 681-693.
