5 Common Misconceptions in the Management of Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) is the most common peripheral vestibular system disorder. Prevalence in the geriatric population is estimated at ~10%.1,2 The condition is typically caused by displaced otoconia, and potentially underlying otolithic membrane, which are free-floating in the semicircular canal (canalithiasis).3,4

The disorder is of strong interest to physical therapists because the condition is diagnosed (Dix-Hallpike) and treated with physical head positioning maneuvers. Medication is typically not helpful and surgical intervention (canal plugging) is only pursued in refractory cases.

Common Misconceptions

To fully understand the management of BPPV it’s important to look at several common misconceptions regarding evaluation, testing, and treatment of BPPV:

  1. “Since my patient is not complaining of vertigo, they are unlikely to have BPPV.”

 Interestingly, many individuals with BPPV report non-vertiginous type sensations (imbalance, floating, nausea, lightheadedness) in conjunction with provocation.5 Many elderly patients with BPPV complain of non-vertiginous postural instability in tandem with symptom provocation. This misconception could cause under-recognition of BPPV, which is typically an amenable disorder.

  1. “Testing and treatment maneuvers for BPPV are best done rapidly.”

 BPPV is a position and gravity dependent phenomena. Completing maneuvers quickly causes negligible additional movement of otoconia.6 Testing and most treatment maneuvers can be completed by steadily maneuvering the head. Aside from being unnecessary, moving the head in a violent manner tends to increase anxiety and injury risk to the patient.

  1. “I have ruled-out BPPV because Dix-Hallpike testing was negative.”

Otoconia migrating through an endolymph-filled semicircular canal can take different paths that create variable amounts of pressure within the canal. If the debris falls along the wall of the canal, it creates minimal pressure and hence a “negative” Dix-Hallpike despite the presence of the condition. If the debris traverses through the center of the canal, maximal pressure is generated. This increases the likelihood of provocation of symptoms and nystagmus.6 Repeated testing is highly advisable when BPPV is suspected based on the patient’s history.7

  1. “The only value of Dix-Hallpike testing is to identify BPPV.”

Although BPPV is the most common cause of positional-type dizziness, there are several alternative causes: blood product in endolymph, multiple sclerosis, vestibular-related migrainous symptoms, ethanol intoxication, and chiari malformation. Careful observation of the nystagmus provoked with positioning tests can provide valuable insight into the etiology of the patient’s symptoms.

  1. “Unable to complete Dix-Hallpike testing with my patient, they do not move well enough.”

Some individuals with limited cervical range of motion or back pain may not be able to tolerate standard Dix-Hallpike testing on a flat table; however, there are many alternatives to enhance patient tolerance. To minimize stress on the cervical spine, testing can be completed with the use of a tilt table or hospital bed with the head side set down 20 degrees below horizontal. Another alternative test is the “Sidelying Test”, which is an advisable alternative test to minimize back pain.8

Appropriate Management

To practically and effectively manage benign paroxysmal positional vertigo (BPPV) it’s important to understand these misconceptions. Combining this reasoning with knowing relevant anatomy, physiology, pathophysiology, examination techniques, and canalith repositioning maneuvers, you can provide appropriate management of BPPV.

  1. Oghalai, J. S., et al. (2000). "Unrecognized benign paroxysmal positional vertigo in elderly patients." Otolaryngol Head Neck Surg 122(5): 630-4, 2000.
  2. Kollén L, Frändin K, Möller M, Fagevik Olsén M, Möller C. Benign paroxysmal positional vertigo is a common cause of dizziness and unsteadiness in a large population of 75-year-olds. Aging Clin Exp Res. 2012 Aug;24(4):317-23.
  3. Parnes LS, McClure JA. Free-floating endolymph particles: a new operative finding during posterior semicircular canal occlusion. Laryngoscope. 1992 Sep;102(9):988-92.
  4. Kao WT, Parnes LS, Chole RA. Otoconia and otolithic membrane fragments within the posterior semicircular canal in benign paroxysmal positional vertigo. Laryngoscope. 2017 Mar;127(3):709-714
  5. Tusa RJ, Herdman SJ: Canalith repositioning for benign positional vertigo. Education Program Syllabus 3BS.002. Minneapolis, American Academy of Neurology, 1998.
  6. Hain TC, Squires TM, Stone HA. Clinical implications of a mathematical model of benign paroxysmal positional vertigo. Ann N Y Acad Sci. 2005 Apr;1039:384-94.
  7. Pollak L. The importance of repeated clinical examination in patients with suspected benign paroxysmal positional vertigo. Otol Neurotol. 2009 Apr;30(3):356-8.
  8. Cohen HS. Side-lying as an alternative to the Dix-Hallpike test of the posterior canal. Otol Neurotol. 2004 Mar;25(2):130-4.