Benign Paroxysmal Positional Vertigo (BPPV)
I remember when I first explained to a patient that they had Benign Paroxysmal Positional Vertigo. I told them it's "Benign" meaning not dangerous, "Paroxysmal" meaning it came on suddenly and is recurrent, "Positional" which is why you get dizzy when changing positions (looking up, rolling over, getting out of bed), "Vertigo" meaning the dizzy sensation of you or the room spinning. At this point, the patient was with me. He understood and felt confident I knew what I was talking about. But then I started explaining that this is all happing because there are crystals floating around in your ear telling your brain that you are spinning. And....I lost him. His response...
“Crystals? You gotta be kidding?”
Trust me, when I first learned about the vestibular system and this particular diagnosis, I was somewhat incredulous. However, understanding what is causing your symptoms helps you understand why vestibular therapists provide the treatment we do, and more importantly, how you can manage it on your own should it occur again in the future. So, hear me out as I explain.
The vestibular system
I like to think of the vestibular system as our own internal gyroscope. It tells us which way is up and in which direction we are moving. It is an intricate organ consisting of three semicircular canals, two structures (otoliths) containing small calcium particles (otoconia...or "crystals"), and the vestibular nerve leading to the brain. You have a vestibular system in each inner ear and it's no bigger than a penny!
Semicircular canals - sense rotation (or spinning-like) movement of the head
Otoliths - sense linear (forward/backward, up/down, left/right) and gravitational movement
Vestibular nerve - receive messages from the semicircular canals and the otoliths about the direction and speed the head is moving and send those messages to the brain. The brain then tells our body what to do in order to stay upright or balanced and keep our visual world in focus.
The otoconia, or "crystals" as some people call them, are calcium particles that reside in the otoliths. This is their home base and where they are supposed to be. However, sometimes they get dislodged from the otoliths and fall into one of the three semicircular canals. Sometimes this happens spontaneously and sometimes it happens mechanically, in the case of head trauma or a concussion. It is also more likely to happen as we age and lose calcium in our bones (osteoporosis). This makes those crystals more fragile and likely to dislodge.
When these crystals fall into one of the semicircular canals, and we turn our head in a certain direction, these crystals move about the canal. This movement produces a signal that gets transmitted via the vestibular nerve to our brain. This signal is telling our brain that we are turning or moving our head in a certain direction at a certain speed; however, our body and our eyes are telling our brain that we are moving in a different direction or at a different speed. When the brain receives these two mixed signals, it produces that sensation of vertigo, or dizziness, and sometimes even nausea. That's our brain's way of telling us, "hey, something is not right!"
Sensation of the rotation, being off-balance, nauseous, or even light-headed
Lasting only a few seconds or up to 1-2 minutes
Brought on by rolling over in bed, getting out of bed, looking up, bending over, or other quick head movements
So while being dizzy and nauseous is no fun, it's a good thing we feel those symptoms so we can do something about it.
Doing something about it. That's where vestibular rehabilitation comes in. Remember there are three semicircular canals in each inner ear where these crystals can fall. Most of the time, they fall into one particular canal ( the posterior semicircular canal), but sometimes they can fall into one of the other canals. This is why it is important to be assessed by a specialized vestibular therapist, as we are skilled at performing and interpreting the various tests required to determine the specific type (or types) of BPPV you may have. Once we've determined where in the canal those crystals are hiding, it's time to get them back to where they belong.
Do you remember those little hand-held mazes with the silver ball? You had to tilt them in various directions to get the ball through the maze and back to the center? Well, that is essentially the treatment for BPPV. We tilt your head in various directions to get the crystals back into the otoliths, their home base. This usually takes between 2-3 treatment sessions. There are specific ways to tilt the head depending on which canal and specifically where in the canal the crystals are.
So do not try to treat yourself without being seen by a professional first, as you may make the problem worse.
So then what?
Your crystals are back where they should be and your dizziness should be significantly improved, if not completely resolved. However, up to 30% of patients will still experience residual dizziness, although much milder than the initial episodes. These people benefit from a few more visits to a vestibular therapist for specific excises to help resolve any lingering symptoms.
There is also the chance that this may reoccur. Approximately 30% of patients who have had BPPV will get it again within 1 year, and 50% within 5 years. But don't worry. Once you've been treated by a skilled professional, they can teach you or a caregiver how to perform the treatment at home. And if you are unable to treat yourself, you can always come back for treatment by a vestibular therapist.
What are the chances I will get BPPV?
We don't know entirely why some people get BPPV and others do not; however, there are some health factors that puts a person at higher risk of experiencing BPPV.
Age - people over 70 years old are seven times more likely to get BPPV
History of head trauma - sustaining a brain injury or concussion can dislodge the crystals into one ore more semicircular canals
History of inner ear infection, such as vestibular neuritis or Meniere's Disease
Vitamin D deficiency, including women who are post-menopausal
Decreased estrogen, including women who are peri-menopausal
History of allergies
History of migraines
Remember, BPPV is "Benign", so completely treatable. I can't tell you how many times I've worked with patients who say, "oh I get dizzy every time I get out of bed, but this has been going on for years, so I just assumed it was a normal part of aging." It is not normal and it can be very easily and successfully treated if done by a professional. So, if any of these symptoms sounds familiar to you, please do not hesitate to make an appointment with a specialized vestibular therapist.