I have BPPV. Which side do I treat first? Can I treat both sides?

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Posted on 24th May 2012 by Clearwater Clinical in BPPV - Diagnosis - Treatment - DizzyFIX

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We are often asked which side to treat with BPPV. This answer is relatively simple. The Dix-Hallpike maneuver is the standard test for BPPV. Basically what happens is that you lie down fast on your back and turn your head to one side (ideally looking up a bit too). After about 30 seconds have passed you will either be dizzy or have no reaction. In this example if you are on your left and you get dizzy on that side then you have left sided BPPV. The same is true vice-versa. Obviously you treat the side on which you have BPPV. However about 10% of people have BPPV on both sides or it is not clear on which side they have BPPV because they didn’t get dizzy during the test but do other times.

The answer to the question about treating both sides is a bit more complicated. If you have BPPV on both sides or are not sure which side you have BPPV then you can indeed treat both sides. People often ask if you can “undo” the Epley maneuver by treating the left side immediately after treating the right side. No you can’t. However, you can cause yourself to be more nauseous and may even throw up. Even worse you run the risk of converting posterior BPPV to horizontal BPPV. What is that you ask,… Well usually people have Posterior canal BPPV meaning the crystals are in the back most balance canal. When you do the treatment maneuver the crystals come out of this canal and float back into the vestibule of the vestibular apparatus (the balance organ). If you get a lot of these crystals floating around in there and then start rolling around again they can float into another balance canal – the horizontal canal. This is actually a much worse feeling BPPV. Luckily it is easily treating by a log roll (something you might accidentally do in bed) so it usually doesn’t last very long.

So in summary we suggest getting a proper diagnosis for BPPV – and treating the appropriate side. If you are unsure on which side you have BPPV or have it on both sides we suggest treating one side for one week then treating the other side for the next week. This avoids confusion as to the diagnosis and also avoids nausea and conversion to Horizontal BPPV.

Epley, Semont or Brandt-Daroff Exercises? Which should I choose?

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Posted on 5th May 2012 by Clearwater Clinical in BPPV - Diagnosis - Treatment - DizzyFIX

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Recently we were asked, “Which is best, the Epley, Semont or Brandt-Daroff for the treatment of BPPV?”.

Like many things the answer isn’t perfectly clear. However, many studies have been done on each one and results have been reported with each maneuver. I’ll address each one below.

1) Brandt-Daroff maneuver (this example is for the Right side):
This maneuver consists of sitting upright with your feet over the side of your bed, lying on your right side with your right ear against the bed, or with your head turned to the left. This first step brings the BPPV particles in your semicircular canals about 1/2 way around the bend of the canal (causing vertigo). Then sitting up. This allows the particles which have moved 1/2 way around to begin to fall back down the same way they came from. Then lying down on your left side with your left ear against the bed or turned a little to the right. This doesn’t really affect right sided particles as it puts the canal in a horizontal position but may stimulate symptoms in left sided BPPV if you have it in both ears.

What this maneuver does is create and stimulate the worst of vertigo in patients with BPPV but doesn’t actually treat the underlying cause. As such it is useful to habituate yourself to your vertigo. However, in light of the following two maneuvers I see no need to ever conduct this maneuver.

2) Semont maneuver.
There are two important differences between Semont and Brand-Daroff maneuvers. 1) Speed and 2) keeping your head pointing toward your left shoulder. Lets go over the example again for the right ear.

Start sitting then lie down on your right side. It is important to turn your head to the left and look up at the ceiling. This will stimulate BPPV. Stay there until the vertigo passes. Now QUICKLY sit up and lie on your left side but KEEP your head pointing over your left shoulder during the entire time. You should now be facing down to the ground. Do not turn your head. Wait there until any vertigo passes. Then sit up.

What has happened here is that the particles move into the bend of the semi-circular canals during the first positions, then when you quickly sit up they don’t have a chance to fall back. Finally, by looking towards the ground on the other side they fall out of the semi-circular canals all together.

Since this maneuver requires speed it can be difficult for the elderly. However, it requires less neck flexibility.

3) Epley maneuver.
This maneuver and the Semont maneuver share the beginning and ending head positions relative to gravity which is why they both work. (start on back with head facing ceiling, end on other side facing the floor). The Epley maneuver is not speed dependant as it doesn’t rely on momentum to carry the particles over the hump of the canal and down the other side.

The maneuver begins on the back with the head turned to the right. In the second step the person rolls their head to the left, then up onto the left shoulder and looks to the ground, then sits up.

Summary

There are a number of devices to help perform the Epley maneuver and most publications now recommend the Epley as the first choice of maneuvers unless there is some contraindication. To my mind there is no role for the Brandt-Daroff exercises unless both the Epley and the Semont maneuvers have failed.

So what does it feel like to have BPPV?

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Posted on 21st November 2011 by Clearwater Clinical in BPPV - Diagnosis - Treatment - DizzyFIX

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If you have had BPPV you will never forget what it feels like. But it is hard to explain to someone else. Many people report spinning: “Like falling off a building”, like “a roller coaster ride but worse”, like “my head was spinning”.

To be honest, as someone who has had BPPV myself, it was really scary for the first few minutes. The irony that I had BPPV was not lost on me. However, until I confirmed for myself that I did have BPPV I was a little worried that maybe I was having a stroke or an aneurysm or something of the like.

Right after I woke up I rolled to the left to get out of bed and it literally felt like the bed got up and smacked me in the side of the held. What had actually happened, of course, was that I had fallen back down onto the bed, but it sure didn’t’ feel like that. Following the initial shock I just held onto the sheets, hoping it would end. I am not sure what I said but I had called my wife in to take a look at me. From her standpoint all she could see was a man half out of bed holding on to the comforter for dear life. After what seemed like ages, but was perhaps 30 seconds, things slowed down, the ride ended and I could see straight again.

Afterwards I felt quite nauseous but didn’t need to throw up. I was, however, a bit afraid to move. Nevertheless, my curiosity got the better of me and lied back down on the bed and I rolled to the left again. Not surprisingly the ride started all over again. This time my wife was ready to look in my eyes and sure enough I had nystagmus, which confirmed the diagnosis of BPPV. In hind sight, perhaps I should have waited longer to conduct my experiment as following the second episode I spent the rest of the morning near the toilet bowl.

Once I had fully recovered and was brave enough to perform my own Epley maneuver I got ahold of the treatment device, put it on, and went through the maneuvers. Of course you do get dizzy during the treatment maneuver but ideally it will be the last time you will spinning. The maneuver went by with tolerable vertigo but towards the end I felt something odd. From a medical standpoint there is a second phase of nystagmus, when you roll up onto your opposite shoulder, just as the particles drop out of the posterior semi-circular canal and back into the utricle of the vestibular apparatus. Perhaps I imagined it, but I am sure I could feel a drop, or a change, or something that was different all of a sudden. I was relieved but not really back to normal. I tried to make myself dizzy again but couldn’t – success – sort of. I was left feeling off balance, wondering if it had really worked or if something else was going on. This feeling lasted a good two weeks. I was never spinning again since that first day (as I treated myself immediately) but I was surprised how long it took to get back to normal and for the off balance feeling to go away. That was about 6 months ago – no more episodes – yet.

Everyone describes their own symptoms differently – feel free to comment on yours below.

Can medications actually cause vertigo?

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Posted on 2nd October 2011 by Clearwater Clinical in BPPV - Diagnosis - Treatment - DizzyFIX

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Someone recently asked, “Do any medications cause vertigo?”

The answer depends on what you mean exactly. Many medications can cause dizziness. This can be the light headedness associated with blood pressure medications to the woozy feeling from narcotics to the sleepy feeling of sedatives. However, vertigo (spinning dizziness) is not often caused by medication unless damage is being done to the organ of balance in the inner ear.

In some cases damage can be temporary or it can be permanent. Some medications selectively target the balance portion of the inner ear and some target the hearing portion. The effects can either be permanent or may go away when the drug is stopped.

So yes – some medications can cause vertigo.

Of all drugs aminoglycoside antibiotics are the most vestibulotoxic (ex gentamicin) and are irreversible. Gentamicin in particular effects only the balance portion of the inner ear and causes vertigo.

Loop diuretics such as furosemide (Lasix) cause reversible ototoxicity, but often affect hearing.

Antineoplastic drugs such as cisplatin cause irreversible ototoxicity (typically they affect hearing only)

Salicylates such as asprin can cause reversible ototoxicity.

Quinine, which was historically used to treat malaria, can cause both vertigo and hearing loss.

Of course these comments are to be taken in a general context and any drug related concerns should be discussed with your own doctor.

Can I do the maneuver more than once a day?

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Posted on 2nd October 2011 by Clearwater Clinical in BPPV - Diagnosis - Treatment - DizzyFIX

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Can I do the maneuver more than once a day? The short answer is “Yes” you can.

However, usually in active BPPV you get dizzy during the maneuver. Many people find this repeated vertigo too much to do again and again. Usually BPPV causes nausea but not vomiting, unless of course you induce the vertigo over and over by repeating the maneuver.

This is the reason I suggest you only do it once or twice a day.

Further, it is not know if multiple maneuvers within a single day is actually more effective than a single maneuver as there is something called fatigue. Fatigue is when, despite the BPPV still being there, you are no longer able to make yourself more dizzy. Perhaps this is something like riding a roller coaster again and again. Eventually it won’t make you sick anymore in the same day. The Nystagmus (eye motion seen by your doctor when you are dizzy) also fatigues so it is difficult to tell much when you have repeated the maneuvers several times. As such some doctors will perform the maneuver up to 3 times in hopes of it being more effective, but there is no evidence for the same day, others will do it only once in a day. There is evidence that a second maneuver ( at a later date) will increase the success rate of the treatment from about 80% to 90%. This is one of the reasons using a self treatment device is useful. You can repeat the maneuver at home and increase your success.

We usually recommend 1-2 times per day for 1 week (or less if there is no more vertigo during the maneuver). If there is still vertigo after 1 week then do the other side. If there is still vertigo after appropriately treating both sides then consult with your physician again about the cause of the dizziness.