Talking the Talk About Walking the Walk

Ryan LaCorte Hillary Petetti, Publications, Specialized Treatments

A question I am often asked when people are diagnosed with positional vertigo is, “Can physical therapy really help my dizziness?” They are usually surprised to find out that physical therapy has been shown to effectively treat positional vertigo and that many of our patients are now symptom free after one treatment session.

What is Positional Vertigo?

The type of vertigo I am referring to is called Benign Paroxysmal Positional Vertigo (BPPV) and it is the most common form of vertigo in both men and women age 60 and older. BPPV is an inner ear disorder that begins when the sensory receptors of the ear known as the Otoconia, made up of calcium-carbonate crystals, break away from their normal home in the utricle (see figure 1) and begin floating around in one of the ear’s three canals. The most common canal these crystals get dislodged into is called the posterior canal. This canal is responsible for telling the brain which direction (up or down) your head is moving in when you move it. The canals play an important part in balance because they send signals to your brain to let it know exactly which position your head is in at every given moment in time. This enables you to have clear vision and helps you maintain balance.

Why Do the Crystals float out in the First Place?

Normal aging is the most common reason the crystals break away and float out of the utricle. As the inner ear ages, some of the crystals can “loosen” spontaneously and float into the posterior canal. Other reasons the crystals of the ear loosen can be attributed to head trauma, viruses that affect the ear, migraines, and, sometimes prolonged periods of inactivity.

Symptoms of BPPV

Once dislodged crystals get into the ear’s posterior canal, head movements such as looking up or down, bending forward or rolling onto the affected ear can trigger an onset of symptoms. These symptoms may include vertigo (a room-spinning sensation), dizziness, lightheadedness, nausea, vomiting, unsteadiness and/or loss of balance. The vertigo symptoms usually come on suddenly and can last up to 60 seconds until the dislodged crystals stop floating around and settle in again at the bottom of the posterior canal. The onset of symptoms usually occurs again each time the person initiates a head movement into one of the provoking head positions; hence the term “positional vertigo”. The condition will cease only when the crystals are out of the posterior canal.

Diagnosis and treatment of BPPV

BPPV can easily be diagnosed by using the Dix-Hallpike Maneuver. (See Figure 2) This is where we position the patient in an upright seated position and then passively move them into a lying position where the head is extended off of the treatment table and rotated right or left to a 45 degree angle. This position usually provokes the patient’s symptoms. The patient is also asked to keep their eyes open during the maneuver so we can detect if “nystagmus” (eye beating) is present. If nystagmus is present, we are able to figure out which canal is affected based on the direction the eyes beat toward. This maneuver is considered the gold-standard for diagnosing BPPV and also indicates to us which of the two ears are affected.

After the maneuver is performed, our next goal is to try to get the dislodged crystals out of the posterior canal and back into the Utricle where they belong. We do this by using a sequence of head positions called the Canalith Repositioning Treatment (CRT). The CRT moves the crystals out of the canal and repositions them back into the Utricle where they either settle or get reabsorbed. Studies show the CRT is effective 80% of the time and helps rid patients of their symptoms in one week. Yes! – I said one week! Patients are always amazed that their symptoms can be relieved in one week with only one simple head treatment – but it’s true and I’ve seen great results with the patients we have treated throughout the years at All-Care.

After the CRT is performed, patients are given a protocol they have to follow for one week after their treatment. This consists of avoiding activities that require them to bend forward, tilt their head upwards, or turn their head quickly to the left or right. They must also avoid sleeping on the affected ear. Patients are advised to sleep propped up or on their backs to ensure the crystals don’t float back into the posterior canal. One week after treatment and appropriately following the protocol, the patient should notice a complete cessation of symptoms and should be able to return to life as normal, making their physical therapy treatment a complete success!

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