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The most common cause of vertigo is benign paroxysmal positional vertigo (BPPV).

Within the bony labyrinth, there are three semicircular canals. Each of these canals contains a viscous fluid called endolymph.

Head movements result in the endolymph bending the tiny cilia that line the interior of the semicircular canals. 

(The dense nature of endolymph explains the residual spinning symptoms for seconds after the offending head movement.)

Cilia stimulation, input from the eyes, and proprioception from the cervical spine combine to determine balance.

Dysfunction of any, or all, of these sensory structures affect balance

  1. Cilia
  2. Eyes
  3. Cervical proprioceptors


Do you want to challenge all three at the same time? Use the Dix-Hallpike Maneuver! Most cases of BPPV affect the posterior semicircular canal. The Dix-Hallpike maneuver is the gold standard for diagnosing posterior semicircular canal involvement. The test has a specificity of 83% and a sensitivity of 52% for BPPV arising from the posterior semicircular canal. 

In older patients, physical activity and vestibular rehabilitation exercises are recommended for more rapid and complete vestibular compensation; repositioning maneuvers are highly indicated and effective in the older population with benign paroxysmal positional vertigo. (1)


Do you want to treat BPPV using evidence-based protocols? Use ChiroUp!


The effectiveness of the Epley maneuver ranges between 78-95%. A single intervention leads to remission in 44-89% of cases, and this rate improves with second, third, or fourth interventions. The addition of vibration does not enhance the effectiveness of this maneuver. 


Although the Epley maneuver shows superior initial outcomes, the Foster Half-Somersault maneuver is a home-based repositioning maneuver for posterior canal BPPV that leads to lower recurrence levels and is generally better tolerated than the Epley maneuver. The Foster Half-Somersault maneuver starts with the patient kneeling with their buttocks on their heels. The patient tips their head straight up to look at the ceiling and holds this position until after any dizziness has faded for several seconds. Next, the patient quickly bends their head and body forward to lightly rest the top of their head on the floor slightly in front of their knees. Their hands should be on the floor in front of their knees to prevent excessive head and neck loading. The patient turns their head toward the affected ear and holds this position until after any dizziness has faded for several seconds. Next, while maintaining head rotation, the patient raises their head to the level of their spine. The patient holds this position until after any dizziness has faded for several seconds, then quickly returns to an upright kneeling position.

If you want to learn about the specific anatomy and a more in-depth explanation of BPPV, check out the condition reference in ChiroUp under the Clinical Skills tab. 

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1. Casani AP, Gufoni M, Capobianco S. Current Insights into Treating Vertigo in Older Adults. Drugs & Aging. 2021 Jun 23:1-6. Link

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