Benign Paroxysmal Positional Vertigo

The Role of Physiotherapy in the Management of BPPV, a common Vestibular Disorder.

What is BPPV?

Benign Paroxysmal Positional Vertigo (BPPV) is a prevalent form of vestibular disorder. It is the cause of dizziness in 50% of individuals who are experiencing dizziness.

In America, over 70 million people over the age of 40 years have suffered from vestibular dysfunction and have experienced chronic balance problems (1). 85% of people over 80 years of age have a vestibular dysfunction, balance impairments (4) and have significant impairments in basic activities of daily living (249).  People with a vestibular dysfunction have an 8-fold increased risk of falling and the cost of falls in the USA has been $55 billion this year (4).

What Causes Vestibular System Disorders?

Causes include head trauma (whiplash, concussion), age related vestibular system degeneration, inflammation of the vestibular system and infections to the vestibular nerve (neuritis or labyrinthitis), BPPV*, Meniere’s Disease, barotrauma (scuba diving), drug toxicity, and acoustic neuroma.

What are Signs and Symptoms of Vestibular Disorders?

People will commonly experience nystagmus (involuntary rapid eye movement), vertigo (room spinning phenomenon), dizziness, loss of balance or ataxia (cerebellar impairment), and compromised gaze stability (blurred vision with quick head movements).

What is Vertigo?

Vertigo is the most common type of vestibular disorder. It is defined as the illusion of movement occurring in the environment that can’t actually be happening. Typically it is rotational. The room is moving around you or you feel as if the “bed spins”.  It could also be experienced as the body moving relative to the environment.  It is a type of dizziness, yet dizziness and vertigo are not interchangeable terms.  Clinically, BPPV is the most commonly experienced vertigo caused by a vestibular disorder. It is calledBenign Paroxysmal Positional Vertigo (BPPV). There is help available! Physiotherapists play a key role in management of different types of vestibular disorders. Let’s take a closer look at BPPV.

Some straight talk on BPPV:

Benign: “It’s Benign…so it won’t kill you, which is a good thing.” Bernard Tonks, Physiotherapist and Vestibular Rehabilitation Practitioner and Educator

Paroxysmal: This means that it can come and go. It is manageable and treatment will help it go away, but for some it can recurrence. Remember it is manageable. Your Physiotherapist will ensure you know what strategies work best for you to manage your symptoms should they return.

Positional: This means that it is provoked by head positional changes such as when looking up, lying down flat quickly, bending forward, rolling in bed. These movements are the most common culprits of vertigo.


This occurs due to displaced otoconia… (what??!!). Otoconia are calcium carbonate crystals (aka ear rocks or debris) that get shifted into the ear’s canal system where they are not supposed to be. This can occur following head trauma or concussion as well as age related degenerative changes to the vestibular system. The addition of this debris in the ear canals causes the brain to sense postural changes that it is not supposed to. This unwanted additional input, essentially causes sensory overload. The brain is overwhelmed with uncalibrated signals.  Uncontrolled rapid eye movement, the sensation of the room spinning, and potentially nausea and vomiting results.

Causes of BPPV include:

  • Vitamin D and Calcium metabolism deficiency
  • Osteoporosis (6)
  • Cardiovascular Disease and vascular insufficiency of the vestibular artery
  • Surgical trauma to the inner ear (3)
  • Head trauma (2) or concussion
  • BPPV corresponds with migraines

Why is physiotherapy crucial to manage BPPV?

BPPV does not show up on CT scans or MRI’s and medication has been shown to be ineffective in treating BPPV!!! Despite this, less than 10% of BPPV patients receive effective treatment (281).

How can Physiotherapy help?

To diagnose BPPV, your physiotherapist will use The Dix Hallpike Maneuver to learn which part of the ear canals are affected with “stuck crystals”. The therapist will use the appropriate technique to relocate the crystals to where they will not cause problems, i.e. relocating them to a safe place. In technical terms, the crystals will move from the canals into the utricle within the ear where they will no longer provoke vertigo. You should experience instant relief. A commonly used treatment technique is called the Eply Maneuver. It is designed to remove the crystals from the posterior ear canal which is affected in 80% of patients suffering from BPPV. Often even 1 Eply Maneuver can provide significant relief. This technique can be further repeated up to 3 times per treatment session to further improve symptoms. Other maneuvers include the Gans Maneuver which is indicated if a patient’s neck pain makes the Eply Maneuver difficult. Please note there are different types of BPPV where the crystals are stuck in different locations of the ear canal which are less common. To avoid confusion, I have focused on the most common form involving crystals in the posterior ear canal. Crystals stuck in less common areas require different techniques that serve the same purpose. This is where a Physiotherapist trained in Vestibular Rehabilitation will be key to your success.

What should I do at home after this?

Don’t worry about it. Postural restrictions do not work. You will not be given an arduous task of maintaining a specified neck position for 12 hours to ensure your ear crystals stay where they should. This is old school, and exhausting. Historically the patient would wear a soft collar for 48 hours and would be instructed to sleep upright. They would be unable to sleep on the affected side for 5 days. The theory was restricting head movement would prevent reoccurrences. Current research has shown this is ineffective. Recommendations published in 2017, recommended no postural restrictions following a repositioning maneuver for BPPV.

An Eclectic treatment approach – Treating the neck!

Ensuring that your dizziness is not treated in isolation, it is also important to assess the neck and determine its involvement in your symptoms. Patients with dizziness due to vestibular dysfunction will have an impact on their neck. If moving head around causes dizziness, the central nervous system will try to avoid dizziness so it tightens the neck musculature to restrict the neck movements that cause dizziness. However, this triggers a vicious cycle. Tightened neck muscles reduce proprioception to the brain which increases sensation of cervicogenic dizziness which will create more neck stiffness, which leads to more dizziness…and so forth. Whiplash or concussion can easily initiate this cycle. Acupuncture or dry needling, massage and/or soft tissue techniques,  coupled with manual therapy of the neck and upper back regions, tied together with an individualized exercise program are part of an evidence based approach to treating your symptoms.

How long does it take to recover?

This is a difficult question to answer. To be completely honest, no one is cured from BPPV. Some patients will have their symptoms return.  Treatment involves shifting ear crystals from a place that provokes symptoms, to a place where they don’t. This shift may not be permanent, as these crystals can move and become provocative again. This is a condition that needs properly assessed and then managed with the support of your Physiotherapist. For those who experience a relapse, rest assured your condition is manageable and you will learn how to self-manage and what signs to look for that indicate you need to see your Physiotherapist again. The uncertainty and stress surrounding a reoccurrence can exacerbate symptoms, the good news is you can enjoy good quality of life, living with BPPV.

Evidence Based Clinical Indicators for Vestibular Rehabilitation:

Clinical practice guidelines published in 2016 indicate there is strong evidence that vestibular rehabilitation provides substantial benefit to patients with vestibular hypofunction. The recommendation is that vestibular rehabilitation should be offered to all patients experiencing dizziness, disequilibrium, motion sensitivity due to vestibular hypofunction (4).

Vestibular rehabilitation should also be considered in the management of individuals post-concussion who have dizziness, gait, and balance dysfunction that do not resolve with rest. (5)


The contents of this paper have been adapted from lectures by Bernard Tonks.

  1. Agrawal Y et al. Disorders of balance and vestibular function in US adults. Arch Intern Med 2009 169(10) 938-944
  2. Balatsouras DG et. al., Benign Paroxysmal Positional Vertigo Secondary to Mild Head Trauma, Ann Otol Rhinol Laryngol 2017 Jan;126 (1) 54-60
  3. Barber SR et al. Benign paroxysmal positional vertigo commonly occurs following repair of superior canal dehiscence. Laryngoscope. 2016 Sep;126(9):2092-7
  4. Courtney D. et. Al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline. J Neurol Phys Ther. 2016 Apr.;40(2):124-155
  5. Hilton MP et al. The Epley (canalith repositioning manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Systematic review 2014 Dec 8;12
  6. Talaat HS et al. Low bone mineral density and vitamin D deficiency in patients with benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol, 2014, June 29 (ahead of print)

Stephanie Gardonio

BPHE, BSc(Biology), MScPT, MCPA

Registered Physiotherapist, Pelvic Health Rehabilitation


Stephanie has curated a Physiotherapy tool box that allows her multiple points of view to meet her patients’ needs. She has taken courses in the McKenzie Method for assessing and treating spinal conditions. She has completed mat and reformer Rehabilitative Pilates courses through Stott Pilates, training she uses to create customized exercise programs. Understanding the roll of the pelvic floor in the effective treatment of low back pain, sacroiliac joint dysfunction, bowel and bladder dysfunction and during a women’s journey from pre-natal to post-natal, she has completed Pelvic Health Rehabilitation courses. She is qualified to perform internal assessment and treatment of the pelvic floor.

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