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Benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness and vertigo. (1-4) The condition is characterized by brief episodes of dizziness, nausea, or nystagmus triggered by head movement. (5) Over seven percent of the population will experience BPPV at some point in their lifetime, and 80% of those patients will require medical treatment. (6,7)

An October 2022 systematic review in Academic Emergency Medicine concluded that canalith repositioning maneuvers (aka Epley maneuver) should be the first line of care for BPPV:

In patients with BPPV, vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up; however, there is evidence toward the superiority of CRM over these medications. Vestibular suppressants have an uncertain effect on symptom resolution within 24 h, repeat ED/clinic visits, patient satisfaction, quality of life, and adverse events. These data suggest that a CRM, and not vestibular suppressants, should be the primary treatment for BPPV. (104)

This conclusion means manual therapists should be the provider of choice for BPPV patients. So, to make sure you own the essential skills, check out this BPPV - Benign Paroxysmal Positional Vertigo Epley maneuver video, including the pre-requisite Dix-Hallpike test.

Want a refresher for your treatment room?

Subscribers can download the following Epley maneuver PDF in the forms library. Not a subscriber? Fill out the form below to receive your download in your inbox!

*The remainder of this blog has been optimized as an interactive experience for ChiroUp subscribers logged in to their accounts.

BPPV Symptoms

The classic presentation for BPPV includes sudden (aka paroxysmal) episodes of rotary vertigo that last 10-20 seconds following head position changes. (5,36) Typical provocative activities involve transitioning between upright and recumbent positions; rolling from side to side in bed; bending forward; and moving the head to look up, down, or side to side. (37)

BPPV Exam

The BPPV exam's primary purpose is to rule out more sinister causes of vertigo and to identify the side (right, left, both) and site (posterior, anterior, horizontal) of the involved semicircular canal. Clinicians should remember that multiple canals can be involved (4.6% of cases), and the condition can be bilateral. (39,97)

BPPV can arise from any semicircular canal (posterior, anterior, and horizontal). The following chart outlines evaluation and management options for each.

The Most Versatile BPPV Test

Most cases of BPPV (60-90%) involve the posterior semicircular canal. (7,40,41) The Dix-Hallpike maneuver is the gold standard BPPV test for diagnosing posterior canal BPPV. (42-44,50) The Dix-Hallpike test has a specificity of 83% and a sensitivity of 52% for posterior canal BPPV. (46,47) ChiroUp subscribers can review the Dix-Hallpike test here.

The Difference Between BPPV and Cervical Vertigo

Cervicogenic vertigo (arising from irritated neck joints) presents with symptoms similar to BPPV, i.e., episodic, provoked by movement, and eased by maintaining a stable position. Patients may complain of light-headedness, floating, unsteadiness, or general imbalance, but rarely true “spinning” vertigo (84). Cervicogenic vertigo is often accompanied by loss of cervical range of motion, upper cervical tenderness, and upper cervical segmental joint restriction. (85,86)

One complicating factor for differentiating cervicogenic vertigo from BPPV is that most provocative movements simultaneously stimulate cervical spine proprioceptors and the vestibular apparatus.

The Head-fixed/body-turn test (aka Neck torsion test) aims to isolate cervical mechanoreceptors without stimulating the vestibular apparatus. (87,88) The neck torsion test is performed with the patient rotating their body on an exam stool while the clinician stabilizes their head, thereby minimizing vestibular input. Reproduction of dizziness or nystagmus when the head is stable suggests a cervical component. (89-91) Subscribers can review the Head-fixed/body-turn test here.

BPPV Treatment

Canalith repositioning maneuvers and BPPV home exercises are the current standard of care for the treatment of BPPV. (40,42,43,47-49) BPPV treatments are predicated upon identifying the involved semicircular canal(s) and then choosing the appropriate maneuver to reposition the wayward calcium carbonate sediment. (2,37) All BPPV repositioning maneuvers attempt to move the head into a position where debris can fall to the top of the problematic canal and then transition the head into a position where the debris moves around the canal back into the vestibule.

The Epley Maneuver

When the posterior semicircular canal is involved, clinicians should choose the canalith repositioning procedure, aka, Epley maneuver for vertigo. (42-44) The effectiveness of the Epley maneuver ranges between 78-95%. (62) A single Epley BPPV maneuver leads to remission in 44-89% of cases, and this rate improves with second, third, or fourth interventions. (2) The addition of vibration does not enhance the effectiveness of the Epley canalith repositioning maneuver for BPPV. (64,65)

ChiroUp subscribers can review the benign paroxysmal positional vertigo Epley maneuver video below, aka, canalith repositioning procedure video.

Pro tips: When performing repositioning maneuvers, movement should be brisk enough to generate sufficient momentum to dislodge displaced canaliths. Clinicians should also recognize these crystals are moving through fluid, which requires an adequate amount of time to settle into a new position. Clinicians should proactively inform patients that although they may become dizzy during testing or treatment, they should attempt to keep their eyes open and remember the intervention will ultimately help ease their symptoms.

Subscribers can review the ChiroUp BPPV protocol for a complete description, including contraindications to performing the Epley maneuver. (i.e., instability, recent cervical spine surgery, vascular issues, detached retina, or advanced arthritis) (73,74)

BPPV Outcomes

Did you know that the ChiroUp Clinical Outcomes & Patient Satisfaction Synopsis found BPPV was the most responsive condition of all 115 ChiroUp diagnoses?

At-Home BPPV Exercises

Home exercises for BPPV can provide supportive benefits. Exercises for posterior canal BPPV include the Foster half somersault and the Sermont liberatory maneuvers. Subscribers can review those here.

Want more BPPV content?

Join our docs for an entertaining and informative discussion about the most common causes of vertigo. This on-demand webinar will include practical skills for managing cervicogenic vertigo and BPPV, plus valuable tips for identifying threatening presentations.

Watch now

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Benign Paroxysmal Positional Vertigo - BPPV