BPPV: From Captivity to Freedom

I have had the opportunity to work very closely with thousands of individuals battling positional vertigo since the year 2000.  These individuals have varied in ages from the late teens to the early 90s.  Many of these individuals have had BPPV and have described the experience as one of the most terrifying events in their lives.  Some have said they would rather have open heart surgery, give birth, have their knees replaced and even go through chemo therapy than battle BPPV. 

Beause of the perceived uncontrollable and unpredictable nature of BPPV, many are held captive by the problem.  Many I see with this problem come in moving as though they are being held under arrest or at gunpoint.  It is very rewarding to be able to help these individuals move from captivity to freedom.

One of my most memorable and rewarding clients I worked with who had BPPV was a client in her 50s.  She had dealt with Multiple Sclerosis for 30 years.  Her MS progressed to the point where she was not able to move her arms, legs or sit up on her own.   The only way she could drive her wheelchair was through use of a head controlled device.  Unfortunately, she developed BPPV.

Because of her BPPV, she was not able to drive her wheelchair without feeling extremely nauseated and sick.  We were able to use the assistance of four staff members and move her so that her calcium crystals would be returned and she would no longer be dizzy.  She was able to drive her wheelchair out of our clinic without being dizzy.

Autoimmune disorders and the inner ear

I am noticing that clients battling one or more autoimmune disorders who are struggling with dizziness may tend to share the following characteristics:

1. Drop attacks/Tumarkin's Syndrome/Otolith Crisis: I have recently had a few individuals with autoimmune disorders report feeling like they are being thrown or shoved to the ground. 
2. More unstable and unpredictable spells of dizziness than someone battling a vestibular problem because of a virus, aging or blood flow compromise.
3. When battling BPPV, repositioning maneuvers may not work as quickly.  BPPV may recur more frequently.  Post maneuver restrictions may be more necessary for these individuals than for individuals battling BPPV from other causes.

Dr. Timothy Hain shares a lot of valuable information about autoimmune disorders and the inner ear here: http://www.dizziness-and-balance.com/disorders/autoimmune/aied.html

A question about really fast nystagmus

I recently had a colleague in the Acute Care setting ask me the following question: "I had a BPPV patient today who had definite left torsional nystagmus when I did the Hallpike. Treated it with Epley's, and when I retested the Hallpike again it was positive (which was not unexpected), but the nystagmus was beating much faster than the first time. Does that mean anything, or was it just a weird coincidence? We ended up doing Epley's two more times, but I think we got it."


The following are some possible answers to her question:

Interesting. Perhaps the torsional nystagmus was more intense the second time because:

1. More caclicum crystals dumped out during the first Dix Hallpike and Epley.
2. The first Epley "mobilized" any adhered calcium crystals (silent debris) so there were more actively available for the second Dix Hallpike. This adherence with a possible "bottle neck" in the canals prevented them from returning the first time. If this "bottle neck" theory were true, whatever caused it during the first CRM must have been gone if the second and third CRMs were a success.
3. The first Epley/Dix Hallpike was not done as quickly as the second...thereby, the first did not create enough momentum to reposition the otoconia the first time. The second may have been faster, caused more nystagmus, but did a better job of shooting the otoconia through the tubes and back to their happy homes.
4. The first Epley/Dix Hallpike caused otoconia to be repositioned into the client's lateral canal.  This may have caused a more intense lateral nystagmus with the subsequent retest. 
5. The second Dix Hallpike may have caused otoconia to dump out into her lateral canal.

Were the following re-tests after the second CRM better?

Is Benign Paroxysmal Positional Vertigo Really Benign?

I believe there are times when Benign Paroxysmal Positional Vertigo is truly benign and I believe there are times when it is not even close to benign.  Whether or not we agree that benign paroxysmal positional vertigo is benign depends upon our definition of benign.  If the term benign means not cancerous or malignant, then BPPV is truly benign.  However, if benign means not life-threatening, not recurrent, not progressive or of no danger to health, then there are times when benign paroxysmal positional vertigo is not benign at all. 

When is BPPV not benign?  I suggest the following examples:
1.  When BPPV is caused by circulatory problems.  In this case, BPPV may be a result of a lack of blood flow to the inner ear.  This could be a sign of more ischemia to come in more important life sustaining places like the brainstem or cerebellum.  In this case, BPPV is a sign of life-threatening problems that may soon occur. 
2. When an individual falls to the floor and injurs something (fractures, head injuries, sprains and strains).  In this case, BPPV is of danger to health and can be life-threatening.
3.  When an individual develops movement phobias because of the intense sensations they experience when they move.  This is of danger to health because individuals often become "scared stiff" and develop disuse dysequilibrium. 
4.  Many cases of BPPV recur frequently.  That is opposite of what some define as benign.

Do you have to feel spinning to have vertigo?

Vertigo is not a diagnosis it is a symptom.  The Vestibular Disorders Association uses the following terminology to define vertigo: Spinning or whirling sensation; an illusion of movement of self or the world. 

I have witnessed individuals with intense nystagmus describe their dizziness as other sensations than spinning.  The presence of nystagmus often represents either a central or peripheral vestibular disorder.    I see people all the time who have vestibular disorders (with nystagmus) and they describe their dizziness as lightheadedness, off balance, funny in the head, etc.  Many clients I see who have been told they have vertigo do not truly have vertigo. 

I have had clients with the diagnosis of Benign Paroxysmal Positional Vertigo present with typical BPPV nystagmus and describe their dizziness as lightheaded...not vertigo. 

Reflux and BPPV

I was recently reminded of the impact of BPPV on reflux.  When BPPV occurs in people with a predisposition toward motion sickness, they may vomit with spells.  If this type of individual also has GERD, the vomitting from the vestibular problem will trigger the GERD to be inflamed.

Once the BPPV is fixed, the client may continue to be nauseated when lying down...but, not because of the BPPV, because of the GERD.