Management & Goal of Benign Paroxysmal Positional Vertigo (BPPV)

Interventions for Benign Paroxysmal Positional Vertigo (BPPV)

1. Three different treatment approaches have been developed on the basis of pathophysiology of the BPPV.
2. The techniques include the canalith repositioning manoeuvre, Liberatory (semont) manoeuvre, and Brandt–Daroff exercises.

Canalith Repositioning Maneuver (CRM) 

1. Also known as Epley manoeuvre.
2. Based on the canalithiasis theory of free-floating otoconia in the semicircular canal.
3. The patient's head is moved into different positions in a sequence that will move the otoconia out of the involved semicircular canal and into the vestibule.
4. Once the otoconia are in the vestibule, the sign and symptoms should resolve.
5. The positions used in the treatment of posterior and anterior semicircular canal canalithiasis can be the same.
6. The procedure of CRM:
1. The patient's head is first rotated 45° toward the involved side. 
2. The patient is then moved into the Dix-hallpike position with the affected left ear toward the ground. 
3. Next, the head is rotated 90° to the right and maintain the 30° extension during this step. The head should now be positioned 45° to the right.
4. The patient is rolled onto the right shoulder and slowly brought up to the sitting position, head still rotated at 45° to the right.

5. Between each step, the therapist should wait for 1 to 2 minutes or until vertigo and nystagmus has stopped to ensure otoconia flow through the canal.

Liberatory (Semont) Maneuver

1. Treatment for posterior semicircular canal BPPV based on cupulolithiasis theory.
2. It involves rapidly moving the patient through positions designed to dislodge the otoconia from the cupula.
3. Liberatory Maneuver or right posterior SCC BPPV: 
1. The head is rotated 45° to the left side. 
2. With assistance, the patient is then moved from setting to the right sideline and stays in this position for 1 minute. 
3. The patient is then rapidly moved 180°, from right side-lying to left side-lying. That should be in the original starting position, left rotated (nose down in the final position). 
4. After one minute in this position, the patient returned to sitting.

Brandt–Daroff Exercises

1. Exercises are designed to habituate the CNS to the provoking position.
2. They may also act to dislodge otoconia from the cupula or by causing otoconia to move out of the canal. 
3. Exercises for posterior SCC BPPV:
1. The patient starts in a sitting position and turns the head 45° to one side (left) then quickly lies down on the opposite shoulder (right). The patient should be instructed to remain in this position for 30 seconds or until the vertigo stops.
2. The patient then slowly returns to the starting position, maintaining the head rotation (left) until sitting upright.
3. The patient turns the head to the opposite direction (right) and nice down on the other shoulder (left), absorbing the similar 30 second time guidelines.
4. The exercise should be done 10 to 20 times, three times per day until the patient is without vertigo for two consecutive days.

Goals of BPPV Interventions:

1. The otoconia will be returned into the vestibule.
2. The patient will demonstrate reduced vertigo associated with head motion.
3. The patient will demonstrate improved balance.
4. The patient will demonstrate independence in a daily activity involving head motion.