POSITIONAL VERTIGO (BPPV) Timothy C. Hain, MD Page. Carol Foster reported another self-treatment maneuver for. Benign Paroxysmal Positional Vertigo? But when they find their vertigo gone with a simple test and a non-pharmacological treatment, “they love it,” he said. “Like an old Post-it note, after 60 or 70 years the stickiness wears off,” said Dr. Carol Foster, an otolaryngologist who directs the Balance Laboratory at the University of Colorado Hospital.
Abstract Benign paroxysmal positional vertigo (BPPV) frequently recurs after treatment, so a home exercise would be desirable. We designed a self-administered exercise, the half somersault, for home use. In this randomized single-blind study, we compare the efficacy of our exercise to self-administered Epley maneuvers in patients with BPPV. Subjects performed exercises twice while observed, were re-tested with the Dix Hallpike, and then reported on exercise use for 6 months.
Outcome measures were the reduction of nystagmus intensity, tolerability of induced dizziness, and long-term efficacy. Both exercises resulted in a significant reduction in nystagmus after two self-applications.
The Epley maneuver was significantly more efficacious in reducing nystagmus initially, but caused significantly more dizziness during application than the half somersault. During the 6-month follow-up, the Epley group had significantly more treatment failures than the half somersault group. We believe that both exercises can be self-applied to control symptoms, but the half somersault is tolerated better and has fewer side effects as a home exercise.
Karger AG, Basel Introduction Benign paroxysmal positional vertigo (BPPV) is a common vertigo disorder in which otoconia normally adherent to the utricle become displaced into the semicircular canals [Lanska and Remler, 1997; Parnes and McClure, 1992; Welling et al., 1997]. These can be cleared from the semicircular canals by canalith repositioning (CRP), resolving the dizziness [White et al., 2005]. This is usually performed by a clinician or therapist.
In the 1980’s, two treatments for the posterior canal variant, the Epley and Semont maneuvers, were independently devised, and both have been found to be similar in efficacy, which exceeds 90% [Epley, 1992; Semont et al., 1988; White et al., 2005]. Other maneuvers have been described for the horizontal and anterior canal variants [Appiani et al., 2001; Casani et al., 2011], and a number of minor variations of all these maneuvers have been reported. Ideally a maneuver is applied several times in the course of one treatment session, until no further symptoms can be elicited [Epley, 1992].
Because particles can again become displaced into the semicircular canals over time, it is possible to have recurrences, which approach 50% over 1–3 years [Beynon et al., 2000; Nunez et al., 2000]. Usually patients with recurrences return to clinic for further maneuvers, but home exercises should be more cost-effective.
These maneuvers have been posted on the internet, depicted in written sources, and are given out by physicians directly to patients who use them to perform exercises at home [Furman and Hain, 2004; Radtke et al., 1999; Radtke et al., 2004]. In order to be used effectively by patients, the ideal exercise should be reasonably simple to learn and apply, and have minimal side effects.
An exercise that successfully relocates the causative particles without causing dizziness would be preferred from a patient standpoint. The Epley maneuver is popular in ENT practices in the U.S. And is often taught for home use [Radtke et al., 1999]. However, it has limitations, listed below, that may reduce its utility as a home exercise. The Semont maneuver has similar limitations. The initial step in the Epley maneuver is the Dix Hallpike (DH) maneuver, a variation of which is also used in the Semont maneuver [Epley, 1992].
This is useful in diagnosis because it places the patient’s eyes in a favorable position for viewing by the physician, and it is designed to trigger a particularly severe spell of nystagmus that is thus more easily observed. The posterior semicircular canal is most sensitive to ampullofugal movements (movement of fluid or particles in the stimulatory direction) and is much less sensitive to ampullopetal movements (the inhibitory direction). The DH causes ampullofugal fluid and particle movement in the posterior canal, maximizing the sensation of vertigo and the resulting nystagmus [Lanska and Remler, 1997]. It is useful to the operator during the Epley maneuver because the nystagmus is enhanced, because it allows diagnosis to take place at the start of a maneuver, and because it moves the particles in the direction of the canal exit.
Only the latter is useful when self-applied by a patient, because in the absence of a viewer there is no benefit to maximizing nystagmus, which causes dizziness that can be severe enough to cause vomiting. A second limitation is the possibility of horizontal canal BPPV (H-BPPV). After performing CRP successfully, the newly cleared particles are located just outside the opening to the common crus of the semicircular canals. If another DH is performed as one of a series of exercises, it is possible for these particles to reflux into the horizontal semicircular canal, creating H-BPPV [Foster et al., 2012]. This can occur in up to 9% of patients during performance of rapidly repeated maneuvers.
When used in a specialty clinic, this is easily diagnosed and treated with H-BPPV maneuvers, but patients generally do not have the expertise to recognize differences in nystagmus indicating this disorder, nor are they trained in treatment maneuvers for it. Snoop Dogg Discography Itunes Torrent there. Although this complication is infrequent, the vertigo and vomiting is severe enough to cause some patients to seek emergency care. This may limit the utility of the Epley maneuver as a home exercise.
A 15-min wait between maneuvers reduces the risk of this complication and was used in this study. The ideal home exercise should be able to be performed by the patient without an assistant. The Epley maneuver requires an operator and often a second assistant to guide the patient through the proper positions. It is possible to self-apply CRP without assistance [Radtke et al., 1999], but the sequence may be confusing when vertigo is also being experienced. We have devised a novel exercise, the half somersault (fig.
) that is able to clear the causative particles from the semicircular canals but does not include the DH or require an assistant. Because it does not include the DH, this may reduce the risk of H-BPPV conversion. A secondary rationale was to reduce the dizziness experienced while the head is initially inverted, by allowing particles to move against the direction of fluid movement, which should slow their transition time and reduce cupular deviation compared to the DH. The head positions and corresponding particle positions are shown in figure and the body positions we designed to achieve these head positions are shown in figure. The first three positions replace the DH.
Although the remaining two body positions differ substantially from the Epley maneuver, the head motions are similar to those used when returning from the side-lying to the upright position in the Epley maneuver. Although we had long prescribed home exercises based on the Epley and Semont maneuvers for recurrences, after introducing this home exercise into our clinic in 2006, we noticed a decline in the number of patients returning with recurrences. Half somersault for right-sided BPPV. After each position change, any dizziness is allowed to subside before moving into the next position; if there is no dizziness, the position should be held for 15 s. A While kneeling, the head is quickly tipped upward and back. B The somersault position is assumed, with the chin tucked as far as possible toward the knee.
C The head is turned about 45° toward the right shoulder, to face the right elbow. D Maintaining the head at 45°, the head is raised to back/shoulder level. E Maintaining the head at 45°, the head is raised to the fully upright position.
Dark curved arrows show head movements. Lighter arrows near eyes show the direction one should be facing. Particle movement during half somersault. Head positions shown in A–E correspond to body positions in figure 1.
A = Anterior canal, P = posterior canal, H = horizontal canal. Small arrows indicate the movement of particles as each position is assumed.
In E, the small arrow indicates particles exiting to the utricle. Large bolded arrows in A–D indicate the final location of the particles for each position.
The angle of view is 90° to the sagittal plane of the head and body in the starting position and in A and B. The posterior canal lies at approximately 50° outside of the sagittal plane and projecting toward the viewer as depicted. In C–E the head rotates 45° from the sagittal plane of the body and the labyrinth is depicted similarly rotated.
This places the posterior canal near the sagittal plane of the body and allows maximal ampullofugal fluid movement as the head is raised. In C, with the head inverted, the plane of the horizontal canal is oriented at an upward angle. On repetition of the maneuver, any cleared particles in the utricle are unable to reflux into the horizontal canal during this step.
This study compares the Epley maneuver with the half somersault maneuver, when performed by patients as a self-treatment for posterior canal BPPV. We wished to determine whether the half somersault and Epley are equivalent in resolving acute nystagmus, discomfort during maneuvers, tendency for re-entry complications, and in efficacy as a home exercise. Patients and Methods This was a prospective, controlled, randomized, single-blinded clinical trial comparing the two exercises for BPPV. The study was performed at a tertiary academic referral center from 2007 to 2010. Our institution has a weekly BPPV clinic. We see over 200 BPPV patients per year in this clinic and perform maneuvers on all patients with BPPV of either the horizontal or vertical canal varieties.
Typically patients are treated with repeated maneuvers until symptom free at a single visit. Inclusion criteria were as follows: 18 years of age or older; a history of symptoms suggestive of BPPV; nystagmus and axis of ocular rotation consistent with unilateral posterior canal BPPV. Diagnosis was performed by direct visualization of the globes during the DH maneuver. Patients presenting with cupulolithiasis, H-BPPV, bilateral BPPV, or nystagmus of any other direction or stemming from other peripheral or central vestibular disorders were excluded. Patients with a history of BPPV symptoms but without visible nystagmus on DH were excluded.
Exclusions included patients who were unable to bend the neck or turn the head safely, sit up, lie down, roll over or kneel on hands and knees, because these movements are required as part of the exercises. Patients unable to tolerate the DH or CRP, or who were unable to assume the half somersault position were excluded. All subjects gave informed consent according to a protocol approved by the Colorado Multiple Institutional Review Board (Principal Investigator C.A. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration. Sixty-eight individuals were enrolled and completed the study, 49 females and 19 males. A diagnostic DH was performed in a treatment room by the PI, and the presence and intensity of nystagmus was recorded using a 1–5 scale (nystagmus intensity score). Another researcher then removed the subjects to a training room, and assigned them via a randomized list prepared by a statistician to either the Epley or the half somersault maneuver.
There is extensive literature evaluating the efficacy of the Epley maneuver (the current standard of care) versus untreated controls. In this experiment, the controls were the patients receiving the Epley maneuver as a home exercise. The experimental group contained those self-treating with the half somersault maneuver. Thirty-five subjects were in the Epley group, and 33 in the somersault group. The subject was instructed in the selected maneuver verbally and with a handout and demonstration, and was observed performing it twice without physical guidance. Subjects were asked to rate the severity of the dizziness they experienced during their exercises on a 1–5 scale (exercise-induced dizziness score).
A handout with written instructions and a diagram of the assigned exercise was given to the subject in a sealed envelope for later home use. This included instructions to wait 15 min between each maneuver performed to reduce the risk of canal conversion or re-entry. We expected that this would reduce the risk of horizontal canal conversion in the Epley group. All patients then waited 15 min prior to returning to the original treatment room. The PI was blinded as to the maneuver type that the patient had learned and used. A DH was then performed by the PI, and the presence, duration and intensity of any remaining nystagmus was again recorded using a 1–5 scale.
To complete treatment and meet the standard of care, any patient with continued BPPV then received maneuvers by the PI (Epley) until they were free of nystagmus and experienced one DH without dizziness or nystagmus. The subjects were provided with a log sheet to record recurrences and treatment results and were instructed to perform their assigned exercise with any recurrence. We defined a recurrence as a return of dizziness for which the patient applied the assigned exercise. This information was collected by mail and by telephone follow-up. All patients with a recurrence not responding to their assigned exercise were offered a return to one of our weekly BPPV clinics for standard treatments. We defined a treatment failure as a return to the clinic for dizziness after use of an exercise for recurrence, coupled with an abnormal DH in the treated ear on exam. Six months after initial treatment, the log sheets were collected and each subject was contacted, their clinical chart was reviewed for recurrences, and they were questioned by telephone to verify log accuracy.
11/68 (16%) of the subjects were lost to follow-up, 6 in the half somersault group and 5 in the Epley group. The half somersault and Epley groups were compared statistically by unpaired T test for initial nystagmus intensity and post-treatment nystagmus intensity. Paired T tests were used to compare pre- and post-treatment nystagmus intensity within each group. Exercise-induced dizziness scores, numbers of subjects with complete resolution of dizziness after two maneuvers, number of recurrences and treatment failures were analyzed by Fisher’s exact test. A significance level of 0.05 was adopted. Results In the Epley group, the initial DH resulted in a nystagmus intensity of 3.51 ± 0.88 (mean ± SD). After two self-performed maneuvers, this declined to a post-treatment score of 1.11 ± 1.17, a 68% reduction in nystagmus intensity.
This difference was significant (p. Published online: April 20, 2012 Issue release date: January – December Number of Print Pages: 8 Number of Figures: 2 Number of Tables: 0 eISSN: (Online) For additional information: Open Access License / Drug Dosage / Disclaimer Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication.
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By Neil Bauman, Ph.D. More than 7 million people in the USA suffer from vertigo, a condition where they feel the room is spinning around them. One of the most common forms of vertigo goes by the tongue-twisting name of Benign Paroxysmal Positional Vertigo (BPPV).
It is also one of the easiest forms of vertigo to treat. In the past you would go to an ear specialist (ENT doctor) and he would typically perform the Epley maneuver on you to reposition the otoconia (tiny rocks in your head made of calcium carbonate crystals). These tiny crystalline rocks help you keep your balance by sensing gravity. They normally reside in the utricle in the vestibular (balance) part of your inner ear.
However, sometimes these “rocks” get jarred out of their normal location and “fall” into one of the three semi-circular canals. (The semi-circular canals sense turning motions in each of three different planes.) When the “rocks” touch the tiny cilia in the semi-circular canals, they generate false balance signals. Carol Foster explains, “The semicircular canals are only capable of sensing turning motions, so the presence of particles moved by gravity causes tilting motions of the head to be incorrectly sensed as violent spinning” (1) or vertigo.
Often the vertigo first strikes you when you are in bed and not when you are standing. This is because when you are upright the entrance to the semicircular canals lies just above the gravity sensors (utricle)—and “rocks” don’t fall upward! However, when you are lying flat on your back, the entrance to the semi-circular canals is located just below the utricle. This means that gravity coupled with side-to-side rolling movements as you roll over in bed can accidentally “knock” the otoconia into the opening of the semi-circular canals.(1) As Dr. Foster explains, “Rolling over in bed to one side can cause a very sudden, strong sensation of head-over-heels whirling that lasts for several seconds and then dies away. If the eyes are open the room can appear to spin violently. Attempting to sit up from lying down, to lie down from sitting, or to roll over while lying down can cause the symptoms to recur.
After getting out of bed, symptoms can be brought on by tipping the head upward (while shampooing or reaching up toward a high shelf, for example), looking back over one shoulder, or by bending over forward and then lifting the head quickly.” (1) The good news is that recently Dr. Foster discovered a do-it-yourself method to reposition these “rocks” and thus alleviate the vertigo. She calls it the Half Somersault maneuver. If you have BPPV and want to try it for yourself, here is the link to the instructions for the. Just be prepared for some vertigo in the process, but it should go away as you progress through these maneuvers. ________ (1) Carol Foster. Benign Paroxysmal Positional Vertigo (BPPV).
Marion Downs Hearing Center. I have used the epley repeatedly without the success I usually have with it. I have just used the half somersault for the first time yesterday. It took 5 repetitions for me to work the particles into the spot where I did not have any spinning at any of the positions. I experienced inductions much stronger than any I have had with the epley. My question is thisdo I need to keep my head level for 48 hours afterward as I do with the epley? I usually sleep for 2 nights at a 30 degree or more slant.
I went to a chiropractor who used an activator tool on my neck behind my right ear. The next day I woke up with vertigo on that side.
He told me to google the Epley Manuever and do it which I was afraid to do on my own. I found the half somersault which looked much easier.
I did it and nearly got sick, broke out in a drenching sweat, and couldn’t walk or drive. My medical doctor put me on Hydroxyzine 25 mg. I did the maneuver exactly 14 days ago and my vertigo is just starting to subside. I never experienced vertigo before and I hope I never do again.
That is if this ever goes away. I’m glad the maneuver works for some people, but people should be cautious and so should Drs./chiropractors telling their patients to do these maneuvers alone. Hi, My general doctor referred me to a PT because of my vertigo symptoms. The PT told me I had BPPV and she did the epley maneuver. During the treatment I experienced extreme dizziness and vomited, afterwards I had chills and fever for 2 days.
She said I would need several treatments since she only got a few back in place. I really don’t want to go again since it was worse than my vertigo experience. I have never been so miserable. Should I go to an ENT for other solutions or try the half somersault? Thanks, Annette. Hi John: It is possible. I’m not an expert on this so can’t really give you a definitive answer.
Do you know that your vertigo is the result of the otoconia being out of place–or could it be from some other cause. The half somersault and Epley maneuver are only for if your otoconia are out of place and have fallen into the semicircular canals. Medication may help you, but my fear is that if you take the medication before you do the maneuvers, you may not be able to tell whether the otoconia are falling into proper position or not. Cordially, Neil. Hi Dianna: When you lost your hearing suddenly, did you also start having balance problems of any kind?
Aqua Timez Alones Download. If yes, then you have a damaged vestibular system. Your balance problems would not be because the otoconia are out of place–so doing the half somersault won’t help. From what you say about the sense of imbalance only lasting about 30 minutes, I don’t think it is the otoconia out of place, but problems with your vestibular system. Typically, tinnitus accompanies hearing losses. Since you had a sudden severe hearing loss, you could expect the tinnitus to accompany it. If your hearing would come back, likely your tinnitus would go away.
What can you do? A lot of people find that wearing a hearing aid gets rid of their tinnitus during the day when they wear it. But the tinnitus comes back at night when it is quiet and you take your hearing aid off. If your tinnitus isn’t really annoying you, the best strategy is to just ignore it, focus on the loves of your life and let it fade into the background. This can take a number of months.
The worst thing you can do is focus on your tinnitus and get upset with it. That will only make it get worse and never go away. Cordially, Neil. I woke up this morning to a spinning room, I have never experienced vertigo until today. If I move my head to the left or to the right the room starts spinning and I get extremely nauseous.
I watched the training video on the 1/2 summersault and I was fine to look up on my knees, but when I try to do the half somersault I started throwing up uncontrollably from all the spinning. Should I try again? I really can’t handle this feeling of nausea and spinning. It is normal to feel way worse doing this before it gets better? Hi Amy: What makes you think that your vertigo is from the otoconia in your inner ears being out of place? The vertigo could be from other causes such as taking an ototoxic medication or a virus, etc.
If this is the case, then the half-somersault maneuver won’t help. I’m no expert on the half-somersault maneuver and don’t know whether trying again is a good idea or not. I’ve just reported on it. If your vertigo is due to the otoconia being out of place, and doing the half-somersault makes it worse, I’d suggest you go to an ENT and have him perform the Epley Maneuver.
Maybe you need professional help at this stage. Cordially, Neil.