The dizzy patient – Managing patients with Benign Paroxysmal Positional Vertigo (BPPV)

“I’m so dizzy, my head is spinning….” Whilst a catchy song by Tommy Roe in the 1960’s, being dizzy is not an enjoyable experience and can be difficult for patients to cope with, let alone for clinicians to manage. One cause of dizziness can be due to Benign Paroxysmal Positional Vertigo.

How Common is BPPV?

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vestibular dysfunction in America. An estimated 5.6 million patients present primarily with dizziness per year, and 17-42% of these are diagnosed with BPPV. In Australia, 30% of people over 65 experience vertigo, and similar rates of incidence of BPPV would be expected. BPPV is common in our elderly population, and is associated with increasing incidence of depression, falls and functional impairment.

Can BPPV be treated?

Fortunately BPPV is very treatable, with appropriate therapeutic repositioning maneuvers being the gold standard. The most recent Clinical Practice Guidelines strongly recommend the Hallpike maneuver when assessment suggests posterior canal involvement, and the Supine Roll test when the horizontal canal is suggested. Youtube has some great videos of the Hallpike and Supine Roll test being performed. For the Hallpike, see https://www.youtube.com/watch?v=KzLWOX770i4 or for the Supine Roll test see Supine Roll Test for Horizontal Canal BPPV - YouTube

How to manage BPPV

A holistic approach is crucial to assessment and management. This includes consideration of vision and hearing, impaired mobility, balance and falls, social supports, current medications, headaches and migraines, mental health, and more. Importantly also is that BPPV commonly occurs in patients who experience head trauma, for example with falls. Therefore, screening for dizziness in this context should be considered.

What are the Common Signs and Symptoms?

Common BPPV signs and symptoms include descriptions of

• nausea,
• dizziness,
• light headedness,
• room spinning,
• unsteadiness, etc.

These symptoms should occur with a change in position, such as rolling in bed, getting out of bed or standing from a chair. Symptoms commonly last less than 1 minute, and are often worse in the morning. While these are common signs, patterns and presentations can vary.

Should I send my patient for Investigations?

When patients meet the diagnostic criteria for BPPV, certain interventions are not recommended based on current evidence. These include radiography and routine use of vestibular suppressant medications, such as Serc or Stemetil. Such strategies may increase cost, time, patient stress, adverse medication interactions and unnecessary exposure to radiation or false-positive imaging.

What can Donvale Rehabilitation Hospital Offer?

Our neurological physiotherapists are trained in differential diagnosis and management of BPPV and other vestibular conditions. Along with our multidisciplinary team, we conduct a thorough vestibular assessment, and develop an evidence-based management plan to help our patients achieve their goals.

Should your patients require assessment and management from our experienced clinicians, please don’t hesitate to contact us. A referral form and brochure can be downloaded from Day Rehabilitation webpage. Referrals can be made to our Day Rehabilitation team via:

References

Balatsouras, D., Koukoutsis, G., Aspris, A., Fassolis, A., Moukos, A., Economou, N., & Katotomichelakis, M. (2016). Benign Paroxysmal Positional Vertigo Secondary to Mild Head Trauma. Annals Of Otology, Rhinology & Laryngology, 126(1), 54-60. doi: 10.1177/0003489416674961

Gopinath, B., McMahon, C., Rochtchina, E., & Mitchell, P. (2009). Dizziness and vertigo in an older population: the Blue Mountains prospective cross-sectional study. Clinical Otolaryngology, 34(6), 552-556. doi: 10.1111/j.1749-4486.2009.02025.x

Patangay, K. (2017). Benign Paroxysmal Positional Vertigo (BPPV). Journal Of Head Neck & Spine Surgery, 1(3). doi: 10.19080/jhnss.2017.01.555562