Treatment of benign paroxysmal positional vertigo

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Herdman, Susan J.

Physical Therapy, June 1990 v70 n6 p381(8)

Reference #: A9184325

Abstract: Vertigo (dizziness), loss of balance, nystagmus (rhythmic eye movements in response to activity), and nausea and vomiting can be caused by disorders of the peripheral vestibular system, or inner ear. One of the common disorders is benign paroxysmal positional vertigo (BPPV), which results in vertigo, usually when the head is tilted backwards. Rolling over in bed, straightening up after bending over, or looking up suddenly often precipitate the vertigo. The cause is frequently unknown, but head trauma, viral nerve infection, and vascular (blood vessel) injuries have been implicated. BPPV occurs most frequently in people over 60 years of age, and instability with compensatory postural changes are often seen. Positional vertigo may be caused by other disorders such as central vertigo, a type of brain disorder, but this type of vertigo does not respond to treatment. Cervical vertigo, which is poorly understood, and perilymph fistula (an abnormal connection between the inner and middle ear) have also been confused with BPPV. Two theories have been invoked for the pathogenesis of BPPV. In each theory, the semicircular canals of the inner ear are thought to be made position- or gravity-sensitive (being already movement-sensitive) by degenerative debris within the canals, which either floats or clings to the canal walls, depending on the theory. Three approaches are available for treatment of BPPV. Brandt's exercises, in which the patient repeatedly moves into the provoking position, are thought to dislodge embedded debris, causing it to move to a location where it no longer stimulates canal sensations. Central nervous system adaptation to the stimulus has also been suggested as the reason for success. The Liberatory maneuver moves the patient to the provoking position and then through several other positions. This is usually a single treatment, and purportedly works by floating debris from the canals. Habituation exercises are based on the concept of habituating the brain response to movement-provoked vertigo. These use provoking positions specific for each patient, and a wide variety of balance exercises may be used as well, to deal with postural changes. Studies have shown that Brandt's exercises and the Liberatory maneuver facilitate recovery, but spontaneous remission also occurs. Other studies have shown that habituation exercises and the Liberatory technique are equally effective in treating BPPV. Guidelines for the evaluation and treatment of BPPV are described.