Benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo is the most common form of otogenic (inner-ear) vertigo. Episodes of vertigo occur in certain head positions, accompanied by nystagmus and nausea and possibly vomiting. The diagnosis is made on the basis of a clinical physiatric examination and, if needed, additional physiatric, ENT and neurological tests and radiological imaging. Infectious, immunological, traumatic, vascular, psychological and drug-induced disorders must be ruled out. Treatment includes mobilisation of the otoliths and endolymph and stimulation of the receptors in the saccule and utricle.
In physiatry we use the Dix–Hallpike, Semont and Epley manoeuvres – or rather, their repeated application – alongside conventional methods. From following our patients, we conclude that otolith mobilisation techniques and provocation tests have a substantial advantage over conventional exercise in the treatment of BPPV, although the two are not mutually exclusive. The techniques are based on repeating manoeuvres that were originally only diagnostic tests for vertigo. Their repeated application has been found to reduce symptoms and sometimes, even after a single session, to resolve them completely.
Dizziness is a very common sensation; there is no one who has not experienced it several times in their life – especially as patients regard many other conditions as dizziness, while a number of conditions that medicine describes as vertigo are called something else by patients. Patients describe the sensation itself in different terms. The key to the diagnosis is to determine exactly what is vertigo and what is not.
Does the patient have vertigo?
Definition: an illusion of movement, usually rotational, of the patient or their surroundings. To make matters more complicated, some types of vertigo have no rotational component, so sticking rigidly to the definition makes diagnosis and treatment more difficult. In practice, a forward drift is rare; the ground may tilt, sink, drop, rise, push to one side or sway. Vertigo is always worse with movement. Associated symptoms: difficulty standing and walking, nausea, vomiting, pallor, sweating. Relief with rest, sitting or lying down, which is often incomplete. Patients may fall during an attack and suffer all the consequences that follow. Associated hearing loss or ringing in the ears implies involvement of the labyrinth or the 8th cranial nerve, among other entities.
What is not vertigo?
Weakness may be described as faintness, but it often leads to restlessness and anxiety, accompanied by palpitations, tremor and sweating. The same can happen with anaemia, orthostatic hypotension or exertion in patients with emphysema. But in none of these conditions is there an illusion of movement or the associated symptoms. Loss of consciousness during an attack points to epilepsy or syncope rather than vertigo.
So BPPV is the most common form of vertigo; it is benign by nature but can considerably disrupt normal life. All other forms are rarer, but more dangerous and more complex to treat.
Treatment uses conventional exercises (broadly speaking, non-provocative) and provocation exercises (Dix–Hallpike, Semont and Epley). The conventional exercises consisted of range-of-motion exercises (flexion, extension and rotation of the neck), exercises on an unstable surface and coordination exercises in front of a mirror. Provocation exercises are performed on the principle of provoking an attack in a safe environment. The Epley and Semont canalith repositioning manoeuvres involve moving the head through a series of specific positions. Both manoeuvres can be repeated several times if necessary.
For the Semont manoeuvre, the patient sits. The patient's head is turned towards the affected side, and the rotation is held throughout the manoeuvre. The trunk is tilted sideways towards the practitioner, with the nose pointing upwards. After 3 minutes in this position, the patient is moved quickly upright without correcting the position of the head and tilted to the other side, now with the nose pointing down. After 3 minutes, the patient slowly returns upright and the head is returned to the central position.
Epley manoeuvre: the patient sits. The practitioner turns the patient's head towards the affected side, and the patient is then brought into a lying position with the head at the edge of the treatment couch. The head is then turned to the other side and slowly rolled together with the trunk, face down at the edge of the couch. Finally, the patient is brought back to an upright sitting position, facing forwards.
Dix–Hallpike: the patient sits supported by the practitioner and is brought into a lying position at the edge of the couch. With support, the head is brought into a horizontal position, then extended (retroflexed) and rotated to the left and right. These manoeuvres have countless modifications.
We use the Dix–Hallpike, Semont and Epley manoeuvres – or rather their repeated application – combined with conventional methods. After provocation manoeuvres in the treatment of BPPV, patients need to be followed up and the results compared with those of the techniques used until now. The key points are good patient selection and an accurate diagnosis: BPPV is a diagnosis of exclusion. Patients with other diagnoses may also have vertigo as their leading symptom, but their results were considerably worse.
The specialist in physical and rehabilitation medicine must rule out infectious, immunological, traumatic, vascular, psychological and drug-induced disorders, which is of crucial importance. The techniques are based on repeating manoeuvres that were originally only diagnostic tests for vertigo. Their repeated application has been found to reduce symptoms and sometimes, even after a single session, to resolve them completely.
