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Physical Therapy for Benign Paroxysmal Positional Vertigo (BPPV): Testing & Treatment

Author Taylor Spurgeon-Hess covers Physical Therapy for Benign Paroxysmal Positional Vertigo (BPPV): Testing & Treatment on BackTable ENT

Taylor Spurgeon-Hess • Dec 20, 2021 • 45 hits

As one of the most common causes of vertigo, benign paroxysmal positional vertigo (BPPV) presents often to both ENT offices as well as vestibular rehabilitation clinics. Physical therapy for benign paroxysmal positional vertigo can provide relief to patients experiencing varying degrees of symptoms, such as dizziness, vertigo and lightheadedness. This article explains both the testing and treatment process for BPPV therapy.

This article features excerpts from the BackTable ENT Podcast with special guest Matthew Johnston who specializes in vestibular rehabilitation for patients with BPPV. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Physical therapy for benign paroxysmal positional vertigo (BPPV) relies on determining the exact location of the problem based on BPPV testing. The issue could reside in one of twelve positions based on the ear (right or left), the canal (anterior, posterior, or horizontal), and the position within the canal (canal itself or ampulla).

• The most common treatment utilized to decrease vertigo in BPPV patients is the Epley maneuver which relocates displaced free-floating particles back to their proper location, the utricle of the ear.

• If symptoms fail to resolve after a few sessions, a patient may be instructed to perform at-home exercises, like the modified Epley maneuver, to increase symptom relief.

• For the majority of patients, there are minimal movement restrictions imposed after treatment, and symptoms may fully resolve after as few as one to three sessions.

A man being evaluated for physical therapy for benign paroxysmal positional vertigo

Table of Contents

(1) Testing for Benign Paroxysmal Positional Vertigo

(2) Determining the Appropriate Physical Therapy for Benign Paroxysmal Positional Vertigo

(3) The Role of At-Home Benign Paroxysmal Positional Vertigo Exercises

Testing for Benign Paroxysmal Positional Vertigo

If after an initial physical evaluation the physical therapist suspects BPPV, the next course of action involves determining the exact location of the problem. The issue could be located in one of 12 positions: the anterior, posterior, or horizontal canal on either the right or left side, in either the canal itself or the ampulla. Commonly, a patient may undergo positional testing, which attempts to reproduce symptoms and stimulate nystagmus. Johnston emphasizes the importance of the timing of the nystagmus when interpreting the results of positional tests, as the length of time the symptom lasts may point to one location of the problem over another.

[Gopi Shah MD]
So let's talk about BPPV. Okay. How do you diagnose it from your standpoint? And then what are, are you doing the Epley for them, and then being like, okay.

[Matthew Johnston, PT]
Sure. Yeah. I think this is a great question. Cause, like you mentioned before, we're looking for symptom reproduction and we're looking for nystagmus in any of the positional tests. So if someone has, we'll go with the most common one. Someone gets put back in the dix hallpike on the right, and they have that, beating, you know, torsional nystagmus, that's a pretty solid test for posterior canal bound it, you know, and then I'm weighing the timeframe.
So if it's, if it's less than a minute, it's in the canal, it's more than a minute it's stuck on the opening of the ampulla. So, it's a lot of timing. It's a lot of assessing symptoms. You'd kind of get an idea of when the nystagmus starts to like dissipate. And that's going to give you a little bit more information about how intense this person's symptoms might be in like, you know, break times and stuff like that.
So, a lot of it is which positional test is positive. I always tell patients there's 12 possibilities. You have three canals on each side, plus an opening on each side. So there's 12 options for where it could be. Usually the anterior canal is pretty unlikely unless they're in like a rollover car accident, or a gymnast, they were unfortunately involved in some sort of explosion or some sort of major, head trauma, but by and large horizontal canal or posterior canal, you know, we're looking at least four different canals there.

[Ashley Agan MD]
So, explain this to me where the 12 is coming from, because I'm counting like three or four on each side that gives me like eight. Where's the, is it, are we talking about combinations?

[Matthew Johnston, PT]
So we're talking about, you have anterior, posterior and horizontal canal on each side. So that's our six. But in each of those options. So each posterior canal, the crystals or the otoconia can be stuck in the canal itself, or they can be stuck in the opening of the canal or the ampulla. So that doubles us to twelve.

[Ashley Agan MD]
Thank you for breaking that down for me.

[Matthew Johnston, PT]
No problem, no problem. And I think that's an important thing, to not necessarily on your guys, and to distinguish, like, are we talking about acanalithiasis vs cupulolithiasis. But something that is in the horizontal canal or the posterior canal, and at least having that like framework, if you're gonna put someone in a horizontal canal, nothing happens, but they're really describing this positional room-spinning vertigo. You know, there could be other possibilities too. And it might not show up on that poster here and dix hallpike.

Listen to the Full Podcast

Vestibular Rehab: A Physical Therapist's Perspective with Matthew Johnston, PT on the BackTable ENT Podcast)
Ep 36 Vestibular Rehab: A Physical Therapist's Perspective with Matthew Johnston, PT
00:00 / 01:04

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Determining the Appropriate Physical Therapy for Benign Paroxysmal Positional Vertigo

Once a patient receives a diagnosis of BPPV and the vestibular therapist determines the correct canal housing the issue, only then can treatment be properly prescribed. Without identifying the canal location, treatment may be mismatched and actually cause an increase in symptoms, such as dizziness and vomiting. The standard maneuver utilized to improve symptoms is the Epley maneuver which relieves vertigo by relocating free-floating particles back into the utricle of the ear. While some research states that one to three sessions will properly treat BPPV, Johnston asserts that each patient requires a varying treatment plan and three sessions may not completely resolve the issue. In the past, patients were instructed to limit movement of their head after treatment, but today, most patients can move about their day normally following a vestibular therapy appointment.

[Ashley Agan MD]
And finding the location is kind of the crux of prescribing the right exercise. Right. Can you talk, kind of a little bit about that?

[Matthew Johnston, PT]
Yeah, you got it. That's exactly right. And I think that's where some, either novice therapists or therapists that might not have that exact skills and in vestibular therapy, you know, maybe one of their patients get some vestibular symptoms and they're going to treat it, just to make that patient feel better.
It's really important to identify the correct canal. Because if you're doing an Epley maneuver, for example, on a posterior canal, but the patient has horizontal canal and vomit, it's kind of a mismatch treatment and it's not quite gonna work. It's just something that you need to be aware of and something that you're just gonna speed up the improvement of the patient if you're matching the treatment to the involvement of the canal.

[Gopi Shah MD]
And are these, just a repositioning maneuver, when they come to see you? And then are there things or certain restrictions afterwards or exercises, I guess, do they still do things for that specific, where you think the lesion is or where the crystals are? How does the post-care for that session work?

[Matthew Johnston, PT]
It kind of depends. It depends like I'm sure all of these answers, but once I treat a patient, I might treat them with one to three maneuvers, like three different times. Like I'll put them through an Epley maybe one to three times in a session, it depends on what their tolerance is. It depends on how symptomatic they are.
And then post restriction or post maneuver of restrictions in the research hasn't been that confirmatory. So yeah, they used to put people in collars and said, don't move your head for 24 to 48 hours. And just something that hasn't, it's kind of fallen out of fad and the research has kind of really disproven that.
So for me, I usually say just kind of do your normal thing. Don't go crazy and like shake your head around, but otherwise just kind of go through your normal day. And I'm sure you guys won't be surprised, but, I think the average person would be surprised that, you know, patients are going to try to make it happen sometimes.
And it's like, don't go out of your way to put yourself in these positions. If it's not something you need to do during your normal life. But something that, I don't give a lot of restrictions in the rare cases that we clear it and then if it comes back and we're kind of like fighting back and forth and we're seeing them for like multiple, if I'm working on like two weeks worth of, BPPV symptoms, I might give them some restrictions, for example, to like sleep with two pillows or try to avoid looking up or down for a day or two, I might give them some general guidelines just to see if we can get a little bit more holding of things where they're supposed to be, until I see them again. And that's only in the rare case where I'm like we're fighting for two, three weeks to get something resolved.

[Gopi Shah MD]
How long does PT usually on average, do you tell patients when they first come see you, specifically for BPPV? Is that like a three session and we're good? Or is it like, listen, this might take four to six weeks and two, three times a week type of thing?

[Matthew Johnston, PT]
I hate to say, I've tried to avoid this answer, but I try to avoid this answer because the research will say one to three sessions for BPPV and then something like six to eight weeks for a vestibular hypofunction. But in my experience, there's so many factors that can dictate whether someone's getting improvement in one to three sessions for BPPV specifically. If they can't get into the maneuver the way I, we need them to do it, or the modifications not quite working, or they can't tolerate it, that might be someone who needs to do a little bit more troubleshooting and might go beyond three visits.
When I first graduated, I would tell, oh one to three sessions, and then patients undoubtedly would be there more than three sessions. And then, yeah, that's a whole nother can of worms.

[Gopi Shah MD]
It's like ear tubes, you say nine to 15 months, and then maybe they fell out at six months or they're in for three years.

[Matthew Johnston, PT]
Yeah. Yeah. There's so many factors outside of our control. So I'm trying to avoid putting an exact timeframe on it and sometimes my colleagues will get people better first visit on eval. They won't even have to come back and then like, I'm struggling with this person for three weeks or four weeks, or vice versa. So it kind of goes in waves. It depends on so many factors of the patient. and it just kind of, it all depends. So the research does say one to three, but I'd have to go back and look at like, is this just like college kids? Or is this like, who is this research on? What was the average age of those people? Comorbidities, those kinds of things.

The Role of At-Home Benign Paroxysmal Positional Vertigo Exercises

In some cases, at-home exercises may supplement treatment and provide relief to patients. The exercises usually include instructing a patient to perform an Epley maneuver on themselves, or utilizing a modified version of the Epley. If the patient's symptoms are substantial at evaluation, these at-home maneuvers may be prescribed prophylactically. Otherwise, a physical therapist may only have a patient perform these exercises if their vertigo fails to resolve after a few sessions. Mobility concerns of patients also limit the utility of at-home treatment, as many maneuvers require speed and positioning that are inaccessible to some patients.

[Ashley Agan MD]
Yeah. What are your thoughts on patients doing the exercises at home on their own?

[Matthew Johnston, PT]
That's a great question.

[Ashley Agan MD]
Should we be encouraging them to, you know, if it's going to take a couple of weeks to get into PT, should we be like, okay, here's a handout, like maybe try to do, you know, an Epley on yourself or one of the modifications, you know, there's like the forward roll or forward bend or something like that, right? I don't know. Maybe you can talk more about that.

[Matthew Johnston, PT]
Yeah, there is a modified one where people are on their hands and knees and they just kind of like bow their head forward and then they kind of bring it back. I've had a handful of patients come in and be like, well, I tried this thing and it didn't quite work. I have not personally seen a ton of like literature or research coming out about that particular one.
So I just don't have personal experience with it, but we will give patients home maneuvers. And that might be someone I have do it prophylactically. Like I might have say, do this once a day, until I see you again next week, or especially if we're having some trouble getting complete resolution, I tend to give them to that people, do this one to three times a day.
Obviously their mobility factor, you know, can they do it on their own is a big important, caveat to all of this. Some patients just can't get into the position or can't get the speed or they're at risk for converting the symptoms into the horizontal canal, and that's just going to be way more symptomatic.
So it kind of depends on the patient, but I have given patients like do this for homework one to three times a day, or once we get resolution and I've seen them for, every three months for the last year for some people just get recurrent symptoms. Well, maybe this would be a good idea to do this every day.
And just kind of flush the canal and get things moving because your day-to-day activities, aren't doing that on its own and you just need something more specific so you can avoid having these symptoms coming back to see me. but each individual therapist has their own kind of style with, if they give them on day one or they don't, you know, it kind of depends.

[Ashley Agan MD]
Yeah. And I guess since you're seeing them, you can actually evaluate, okay, this person, they can do it on their own. I've watched, you know, you're able to see it and be like, okay, I'm comfortable with them doing it. I think, I've heard in the past, like other colleagues be like, oh, don't send patients home with exercises cause they could convert it to, you know, a different canal and then things are worse. And so, I think it's, it's very patient dependent and specific. Some patients, you know, need something to do, you know, before they get to PT because they're just going crazy. So you need to give them something. But yeah, it's definitely patient specific, I get that.

[Matthew Johnston, PT]
Yeah, I think it's appropriate for ENTs to give maneuvers for patients at home if they are confident in which canal it is. Yeah. And location exactly. More often than not, patients will be like, well, I'm doing these exercises. And, then I'll kind of make the motion of like laying on your side and turn your head up.
So they're going to be doing Brandt Daroff exercises. And that's just something that's vague, in my opinion, it's just going to irritate patient's symptoms. There is research that, is it effective? Yes. But in acute stages, the more we can kind of line up canal environment with treatment, the more successful that patient's going to be.
I have prescribed Brandt Daroff exercises in a handful of cases. And those are the people who we just can't get resolution or, the testing is kind of coming up inconsistent. And then I send them to get, testing with like a Frenzel lenses or goggles and they still just haven't quite gotten it.
And I'll just say, well, just get your body moving. And like, maybe we just need to desensitize you. And that's where the Brandt Daroff exercises come into play. But I think if the ENTs are confident and this is, you know, posterior canal especially, go for it, do that, I believe there's no restrictions for the patient.

Podcast Contributors

Matthew Johnston, PT discusses Vestibular Rehab: A Physical Therapist's Perspective on the BackTable 36 Podcast

Matthew Johnston, PT

Matthew Johnston, PT is the clinic director at Excel Physical Therapy and Fitness in Philadelphia, Pennsylvania.

Dr. Gopi Shah discusses Vestibular Rehab: A Physical Therapist's Perspective on the BackTable 36 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Dr. Ashley Agan discusses Vestibular Rehab: A Physical Therapist's Perspective on the BackTable 36 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2021, November 9). Ep. 36 – Vestibular Rehab: A Physical Therapist's Perspective [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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