Move Forward Guide

    Physical Therapist's Guide to Benign Paroxysmal Positional Vertigo (BPPV)

    Every year, millions of people in the United States develop vertigo, a spinning sensation in your head that can be very disturbing. Benign paroxysmal positional vertigo (BPPV) is one of the most common types of vertigo. If you've been diagnosed with BPPV, you're not alone—it's estimated to affect at least 9 out of every 100 older adults. The good news is that BPPV is treatable. Your physical therapist will use special exercises and maneuvers to help.


    What Is BPPV?

    Benign paroxysmal positional vertigo (BPPV) is an inner-ear problem that causes short periods of dizziness when your head is moved in certain positions. It occurs most commonly when lying down, turning over in bed, or looking up. This dizzy sensation is called vertigo.

    A layer of calcium carbonate material is present naturally in one part of your inner ear (the utricle). BPPV occurs when pieces of this material break off and move to another part of the inner ear, the semicircular canals (usually the posterior canal). These tiny calcium crystals (otoconia) are sometimes called “ear rocks.”

    When you move your head a certain way, the crystals move inside the canal and stimulate the nerve endings, causing you to become dizzy. The crystals may become loose due to trauma to the head, infection, conditions such as Meniere disease, or aging, but in some cases there is no obvious cause. It’s possible that BPPV might run in families. Some people report that their BPPV symptoms recur predictably, perhaps seasonally or with changes in the weather.


    Inner Ear: See More Detail


    How Does it Feel?

    BPPV occurs most commonly when lying down, turning over in bed, and looking up. This dizzy sensation, called vertigo, usually lasts only a few seconds up to a minute but can make you feel like the room is spinning around you. It may also make you feel lightheaded, off balance, and nauseous.


    How Is It Diagnosed?

    The diagnosis of BPPV is based on whether you have a particular kind of involuntary eye movement (called "nystagmus") and whether you have vertigo when your head is moved into certain positions. Your physical therapist will perform tests that move your head in specific ways to see whether vertigo and involuntary eye movement results. If you have neck or back problems, the therapist might use a test that allows you to lie on your side while movements are made. These tests will help the therapist determine the cause and type of your dizziness and whether you should be referred to a physician for any additional testing.


    How Can a Physical Therapist Help?

    No medication has been found to be effective with BPPV and, in some cases, medication could cause more harm. Fortunately, most people recover from BPPV with a simple but very specific head and neck maneuver performed by a physical therapist. The maneuver is designed to move the crystals from the semicircular canal back into the appropriate area in the inner ear (the utricle).

    The most common treatment is called the Epley maneuver. The physical therapist shows you how to move your head through a series of 4 positions, with the head staying in each position for about 30 to 60 seconds. In the Semont maneuver, the body is rapidly moved from lying on one side to lying on the other.

    Depending on information from your test results, you might be asked to perform Brandt-Daroff exercises, which need to be performed several times per day for several days; however, these exercises have not yet been shown to be effective in clinical trials.

    In a very few cases, BPPV cannot be managed with treatment maneuvers, and a surgical procedure called a “posterior canal plugging” may be considered—but that's usually a last resort. It's rarely ever done.


    Can this Injury or Condition be Prevented?

    There is no known way to prevent BPPV. Symptoms can return if new crystals break off and get into the semicircular canal or if you dislodge loose crystals by placing your head in a certain position.

    It's estimated that within 3 years of having BPPV, about 50 percent of people may have a recurrence. If a head injury caused your BPPV, your risk of recurrence is even greater. Although your BPPV might return, you'll be able to recognize the symptoms and keep yourself safe until you can get help. Your physical therapist will apply the appropriate maneuver to return the crystals to their correct position in the inner ear and also will teach you how to do exercises that can reduce or get rid of the problem.


    Real Life Experiences

    Laura B. is a 68-year-old woman with vertigo that began one morning 2 weeks ago when she got out of bed and the world started to spin. Since then, she's been having vertigo, nausea, and problems with her balance. When she visits her physical therapist, he gives her a special questionnaire to find out exactly what brings on her dizziness and balance difficulty. Turning over in bed and bending over or looking up cause her the most severe symptoms.

    The physical therapist reviews Laura's medical history to make sure that there is no past condition that might be important to her problem. He performs an examination, explaining what tests he will use and that Laura should try to keep eyes open and stay in position. The tests show that in certain positions, Laura's eyes move when they shouldn't, and she has vertigo that lasts 5 seconds. The therapist determines that she has the "canalithiasis form" of vertigo, which means that some crystals are displaced and are located in her semicircular ear canals, causing her vertigo.

    The therapist uses "canalith repositioning" to move the crystals into a proper position, using the Epley maneuver. Afterwards, he asks Laura to wait in the waiting room for a while. He then does a re-test. Laura no longer has the symptoms that she had when the therapist tested her the first time, so he shows her how to do the canalith repositioning maneuver at home. She is to do the maneuver once every day in the morning for one week and then will return to the clinic to make sure that she is progressing as expected.

    This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.


    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat people who have dizziness and balance problems. You may want to consider:

    • A physical therapist who is experienced in treating people with neurological problems. Some physical therapists have a practice with a neurological or a vestibular rehabilitation focus.
    • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in Neurologic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

    You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist (or any other health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with inner ear injury.
    • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

    The following articles provide some of the best scientific evidence about treatment of BPPV. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

    Hillier SL, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2011;16;(2):CD005397. Systematic Review. Article Summary on PubMed.

    Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review.  Phys Ther. 2010;90:663–678. Free Article

    Cohen HS, Sangi-Haghpeykar H. Canalith repositioning variations for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2010;143:405–412. Free Article.

    Clinch CR, Kahill A, Klatt LA, Stewart D. Clinical inquiries: what is the best approach to benign paroxysmal positional vertigo in the elderly? J Fam Pract. 2010;59:295–297. Review. Article Summary on PubMed.

    Bhattacharyya N , Baugh RF, Orvidas L BD, et al, American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139:S47-81. Article Summary on PubMed.

    Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70:2067-2074. Free Article.

    Authored by Susan J. Herdman, PT, PhD; Shannon L.G. Hoffman, PT, DPT; Marcia Thompson, PT, DPT; Bob Wellmon, PT, PhD, NCS; and APTA’s Section on Neurology. Reviewed by the MoveForwardPT.com editorial board.