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.

Why won't my BPPV go away?

Does repositioning work for everyone who has BPPV?  Is it possible to predict, in the first visit, who will benefit from repositioning maneuvers and who will not?  In other words, if a client's history is consistent with BPPV (spinning or other related type of dizziness that increases lying down, rolling over, bending over, etc), is it possible to determine, in the first visit, whether or not the Epley Maneuver or other type of canalith repositioning maneuver will be helpful? 

I believe that it is possible to predict which clients are likely to benefit and which clients are not likely to benefit from repositioning within the first visit.  There are a variety of factors I have found that may help to make this prediction.  Here is one:

1. How long has the BPPV been truly* present?  If the BPPV has not ever gone away (been around for months or years) and the client is an active individual and has been moving normal- no avoidance, then it is odd that the individual has not repositioned the otoconia/calcium crystals/rocks on their own by accident.  At this point, I sometimes suspect that either the individual has vestibular atelectasis or there is some other problem blocking return of the otoconia back into the vestibule.   In addition, it may be that the individual is self repositioning, but that something is causing more otoconia to fall out regularly (from some location in the vestibule). 
1. I have found repositioning maneuvers to be helpful for these individuals at times. 
2. Sometimes, these individuals need greater variants of repositioning maneuvers and post-maneuver restrictions.
3. These clients usually have much more challenging cases.

Another possibility is that the person has a different cause of their dizziness- one that mimics BPPV.

*This predictive factor is only helpful if the client's BPPV has truly not ever gone away on it's own.  Many insist their BPPV has never gone away when it has.  The problem just returns within months.  Because clients experience BPPV that returns, even though it goes away for a period of time, many will say it has not gone away.

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

What Is Secondary BPPV?

I believe secondary BPPV is BPPV caused by another vestibular dysfunction. For instance, neuritis may cause swelling around the nerve, which could push on arteries that supply blood to the otoliths. This could cause the system to become necrotic and now the person is more likely to get BPPV. Meniere's slowly destroys the otoliths and the rest of the inner ear causing one to be more likely to develop BPPV. A person who has TIAs may not only have poor circulation to their brain, but also to the inner ear...this could be an example of secondary BPPV. In this last case, BPPV would not really be so benign because it's cause is actually life threatening. 

Vestibular dysfunction is a process

that may occur over time.  There are some who experience vestibular dysfunction once or twice over the period of several years while there are others who battle the problem much more often.   When it comes to helping these individuals, I believe we need to be careful how we educate people regarding what they should expect for the future.  Sometimes I think looking at vestibular dysfunction one day in the clinic may be like looking at a digital picture of the following:

Snow: is it melting or freezing?
(Is the inner ear in the process of getting worse or better?)

Rain: just began or stopping?
(Is the inner ear problem at it's early stage or is it almost done running its course?)

Building being built: is it a home or office (Is the inner ear problem BPPV or is it signs of Menieres, Vascular Insufficiency or Autoimmune Dysfunction?)

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?

My Top Interests In Vestibular Rehabilitation for 2011

Here are some of my greatest contemplated topics in vestibular rehab for 2011:
1.  HINTS to diagnose stroke
2.  Pseudospontaneous nystagmus
3.  Multicanal BPPV treatment
4.  Implications of GERD, Panic Attacks, History of Syncope when treating clients with BPPV
5.  Secondary BPPV
6.  Stages of BPPV: Dumping, Dumped and Recovery
7.  Motion Sickness and BPPV
8.  Vertebral Artery Dissection prediction
9.  Migraine and other central causes of dizziness
10.  Timing of vestibular rehabilitation and neck therapy working with clients with dizziness.
11.  Over 200 words used to describe dizziness
12.  Nystagmus suppression during normal activities of daily living
13.  Spatial disorientation training in younger and older adults
14  Tai Chi to help teach people to relax when off balance
15.  Many balance disorders seem to manifest themselves in hyperactive balance performance
16.  Imagination, memory and central preprogramming in clients with dizziness
17.  Post Concussion Syndrome in the elderly
18.  The Highly Sensitive Person with vestibular dysfunction
19.  Cardiovascular causes of central and/or peripheral vestibular dysfunction
20   Vestibular Rehab as an examination tool
21.  Evaluating the vestibular system using the video eye movement recording device over time to track changes in vestibular function
22.  Toxic, metabolic and hormonal causes of peripheral and central vestibular dysfunction
23.  Sensory processsing disorders in the adult