| Posted On Jan 10, 2017 | By:

Experiencing vertigo for the first time can be a pretty scary event. Most people describe it as a strong spinning sensation or a feeling of light-headedness or being totally off-balance. Vertigo often stems from a problem with the vestibular system, our balance center which is located in the inner ear but deeper than our ear drum and the systems involved with hearing.

One of the most common causes of vertigo is called BPPV, or benign paroxysmal positional vertigo, a bit of a mouthful that simply means a non-threatening, spinning sensation that comes and goes.

How does someone develop vertigo, particularly BPPV? The most common reason is actually no reason at all! Sometimes it’s triggered by changes in pressure (like when you fly) or changes in climate, but more often than not it just happens. BPPV is an acute condition, and people often complain the vertigo sensation lasts less than a minute and is tied to some sort of motion – e.g., “Every time I look up,” or “Every time I roll over or get out of bed.”

So what’s happening in the body to cause BPPV? In the vestibular system, there is a sac that contains calcium crystals and there are 3 tubes (the semicircular canals) filled with fluid that connect to that sac. That whole system together helps us with our equilibrium. The calcium crystals are weighted and provide our center of gravity, and the 3 connecting canals each detect a different type of motion – how fast you are moving, what direction you are moving in, etc. BPPV occurs when the calcium crystals get dislodged and float in one or more of the canals, disrupting and in essence garbling the signals your body should be getting to accurately detect your motion. This causes the spinning or off-balance sensations of vertigo.

The first thing we have to do in treatment is detect which canal the crystals have entered. We do this through a series of tests which position and move your body in very specific, prescribed ways. If the crystals are in a certain canal that provides your body’s equilibrium for that position or movement, they will shift when you perform it and you may experience the spinning sensation. You may also experience a nystagmus (or movement) of your eye, and based on the direction your eyes move and the duration of the nystagmus, we can also tell which canal is affected.

The Dix-Hallpike test, assessing the left ear. I am looking for a nystagmus (non-purposeful movement of the eyes) that would indicate loose crystals (otoconia) in the left inner ear. A positive test means the patient has BPPV of the left ear.

After that, we perform a particular series of body movements to redirect the crystals back into the sac. For example, the most common canal to be affected is the posterior canal, and we treat that be performing what is called the Epley Maneuver. These movements do trigger the spinning sensation as they are meant to shift the crystals out of the canal. We wait for the spinning to pass, then perform another, deliberate position to continue moving the crystals through the canal and back into the sac. Usually, it only takes two appointments: the first to identify the canal in question and the next one to finish repositioning the crystals in the sac.

Step 3 of the Epley maneuver to treat BPPV of the right ear. The Epley maneuver is the standard treatment for BPPV of the anterior or posterior canal of the inner ear (most common) and consists of 4 specific movements/positions.

It’s a little more common for older people to experience vertigo, as the sac’s elasticity weakens over time. Vertigo also has about a 50% recurrence rate as again, the sac is weakened from the original dislodgement.

The good news is that two out of three cases resolve on their own (sometimes without making any concerted effort at all), and there are also at-home movements you can perform. Once I have treated someone, I review the at-home treatments that can be tried if the very same vertigo symptoms/experience does recur. (Note that the exercises are not preventive so you should only consider performing them if vertigo symptoms return.) At-home treatments are more general and less specific as we cannot know which canal is affected, so they may not correct the problem.

You should contact your primary care doctor or your physical therapist if:

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About Lisa Falvo, PT

Lisa Falvo has worked at the Harvard Vanguard Kenmore practice of Atrius Health since 2014. Before that, she worked at another outpatient practice in the Boston area. She is a vestibular rehabilitation specialist but also treats a wide variety of orthopedic conditions for which physical rehabilitation is necessary. A native of New York, she went to school at Quinnipiac University in Hamden, CT, but after completing her final internship in Boston, she fell in love with the area and made it her home. In her spare time, Lisa thoroughly enjoys yoga and tries to incorporate it into treatment whenever appropriate. Lisa was honored as a co-award winner of the Atrius Health 2016 PT Clinician of the Year, due in large part to her work developing our vestibular rehabilitation capabilities at Atrius Health.