BPPV HOT TAKES

LET'S SAY IT LOUDER FOR THR PPL IN THE BACK...

Despite its prevalence and strong evidence supporting effective physical maneuvers for treatment, BPPV remains under-recognized and often mismanaged, especially in older adults who may not report classic vertigo symptoms.

This episode of Neuron Navigators, hosted by J.J. Mowder-Tinney, a seasoned physical therapist, features an in-depth conversation with Jeff Walter, an expert in vestibular rehabilitation, focusing primarily on Benign Paroxysmal Positional Vertigo (BPPV).

Key points include the importance of focusing on symptom triggers, timing, and associated symptoms rather than solely relying on patients’ descriptions of dizziness quality, which can be unreliable. Jeff introduces the concept of vestibular agnosia, where some patients, particularly elderly or those with brain injury, have BPPV but lack conscious perception of vertigo, thus increasing fall risk without overt complaints of dizziness

The podcast also presents recent advancements, such as the “Loaded Dix-Hallpike” test, a modified diagnostic maneuver that improves sensitivity in detecting BPPV by positioning the head forward before the classic Dix-Hallpike test, allowing better movement of debris in the canal and longer-lasting nystagmus.

The Many Highlights from this episode:

1. If you go back in time, there was a big emphasis on discerning from the patient what they were feeling in terms of symptom quality—meaning questioning/badgering to determine: Do you feel like you're going to pass out? Do you feel wobbly? Spinning? Floating? All these different terms. What we’ve learned is that patients are highly unreliable in reporting their symptom quality… so don’t trust it too much in your differential diagnosis. It should be weighted low.

   
   

2. There's a big emphasis in the literature on putting your stock in triggers, timing, and associated symptoms:

   • Triggers (i.e., what sets off the vertigo or dizzy spells): For BPPV, it should be a change in the orientation of the head relative to gravity - like going from sitting to supine, rolling over, or tipping your head up to look at something on a high shelf.

     • BPPV should have positional triggers, not just any ol' head movement. Generic upright head movements (like turning left or right) don’t really shift the otoconia in a meaningful way. You need to change your head’s position in relation to gravity.

   • Timing should be seconds, although patients often overestimate:

     • Example: If you wake up and roll over or sit up and get an attack of BPPV, you might spin for 20–30 seconds and feel intense rotation or imbalance. But then you might feel sick and unsteady for another 10–15 minutes. So when we ask how long the attack lasted, the patient might say 15 minutes - even though the actual nystagmus lasted only about 20 seconds. That’s because they’re very sensitive to symptom provocation.

   • There should be a lack of cochlear symptoms. Some vestibular disorders come with hearing loss or ringing in the ears, but BPPV should not. BPPV is a peripheral disorder, and should not present with what we call “aural” symptoms (e.g., hearing loss or tinnitus). Other red flag associated symptoms to watch for include: double vision, dysarthria, dysphagia, or hiccups that won’t stop - these can occur with central-origin vertigo.

     
     

3. Identifying central vs. peripheral disorders is especially important if you're an ER or acute care provider. It’s becoming more common to get the vestibular therapist involved quickly because we're cheap, and MRIs are not. If we have a clear history and supporting testing for BPPV, we may be able to forgo CT/MRI.

   • Jeff stated that one study showed that if you show up at the ER with 'vertigo', your chance of getting a Dix-Hallpike test is 9%, while your chance of getting a CT scan is nearly 50%.

     
     

4. Remember the central concerns —> the 5 D's:

   • Diplopia (double vision)

   • Dysarthria (trouble speaking)

   • Dysphagia (trouble swallowing)

   • Limb discoordination

   • Dizziness

     
     

5. New term: vestibular agnosia (lack of perception of sensory stimulation):

   • Some patients—especially elderly individuals or those with traumatic brain injury—can have a vestibular disorder like BPPV and have no conscious perception of it. In other words, they don’t report feeling dizzy.

     • So why bother treating it? Because they still fall, and they still show nystagmus during testing. Reflexively, it's occurring, they just don’t consciously perceive it.

     • This may happen when pathways in the right temporal lobe are damaged due to brain trauma or dense white matter disease. They’re just not getting the higher-level perception of vestibular illusions.

       
       

6. The “Loaded Dix-Hallpike” test is a modified maneuver that improves sensitivity by positioning the head forward before the classic Dix-Hallpike. This helps move debris within the canal and produces longer-lasting nystagmus.

   • How it works: Turn the head 45°, just like the standard Dix-Hallpike. Then incline the patient’s head forward and hold for 15–20 seconds before dropping them back into 20–30° of extension. This migrates the debris toward the cupula so that when you drop them back, the debris has a longer distance to travel, creating longer pressure on the cupula and longer-lasting nystagmus.

   • Inclining your patient forward 30° before the Dix-Hallpike enhances test sensitivity - up to 95%.

   • A video of the “Loaded Dix-Hallpike” can be found in the podcast’s show notes.

     
     

7. If you don’t have goggles, you’ll need to be more vigilant.

   • During the test, focus on one eye, you don’t need to watch both. If the ocular motor system is intact, both eyes will do the same thing.

     
     

8. Lids clench shut as an ingrained reflex when someone experiences vestibular discomfort.

   • It’s important to keep the patient’s eyelid open during testing. Don’t be afraid to gently prop the lid open with your thumb under their brow. They’ll prefer that over hearing you say, “Let’s do that test again.”

     
     

9. For “frequent flyers” (patients with recurrent BPPV):

   • Check vitamin D levels (aim for a minimum of 39).

   • Advise sleeping with the head of the bed slightly elevated. A slight incline helps prevent the debris from settling into the canal in the first place.

     • Options include a small wedge, an extra pillow, or placing a blanket roll under the head of the mattress to create a gentle slope.

       
       

10. Numerous studies suggest that the sensitivity of a single Dix-Hallpike is around 80%.

    • That means there’s a 1 in 5 chance of a false negative.

    • So don’t rely on a single test to rule out BPPV - repeat testing is advised.

      
      

11. You don’t need to perform positioning tests like the Dix-Hallpike or roll test with excessive force. “This disorder is not dependent on you jerking your patient’s head around with high velocity. It’s a gravity-dependent phenomenon.”

    • Helpful analogy: Think of a snow globe. Whether you turn it upside down slowly or quickly, the snow eventually settles at the bottom. The same applies here - otoconia (the “debris”) respond to gravity, not velocity.

    • What this means: Don’t inch them down slowly or do it in segments. Just move steadily and confidently.

    
    

12. “We almost feel like we should rename the disorder. It’s called Benign Paroxysmal Positional Vertigo, but many geriatric patients suffering from it just feel like they’re going to fall. They feel like their balance is off — they don’t always describe it as an illusion of rotation.”

    • What this means: Don’t neglect to check for BPPV, even if your patient isn’t complaining of vertigo!