Georgia Chiropractic Neurology Center

Brain Based Treatment for the 21st Century!

Benign Paroxysmal Positional Vertigo (BPPV) is a prevalent vestibular disorder characterized by brief episodes of vertigo triggered by specific head movements. Understanding its nuances, including the distinction between central and peripheral vertigo, clinical presentation, the predominance of posterior canal involvement, diagnostic maneuvers, age-related considerations, potential causes, and chiropractic neurology treatment options, is crucial for effective management.

Central vs. Peripheral Vertigo: Key Differences

Vertigo, the sensation of spinning or dizziness, can originate from peripheral or central sources. Peripheral vertigo arises from issues in the inner ear or vestibular nerve, with BPPV being the most common cause, accounting for over half of all peripheral vertigo cases. In contrast, central vertigo stems from problems in the central nervous system, such as the brainstem or cerebellum. Differentiating between these types is vital, as central vertigo may indicate serious neurological conditions.

Clinical Presentation of BPPV

BPPV manifests as sudden, brief episodes of vertigo, typically lasting less than a minute, triggered by specific head movements like looking up, bending over, or turning in bed. These episodes may be accompanied by nausea but usually lack auditory symptoms such as hearing loss or tinnitus. The hallmark of BPPV is positional nystagmus—rapid, involuntary eye movements induced by changes in head position.

Predominance of Posterior Canal Involvement

The human ear contains three semicircular canals: anterior, posterior, and horizontal. BPPV most commonly affects the posterior canal due to its anatomical orientation. The posterior canal’s position makes it more susceptible to the accumulation of dislodged otoconia—tiny calcium carbonate crystals—that migrate from the utricle into the canal, leading to vertigo upon head movement.

Diagnostic Maneuvers: The Dix-Hallpike Test

The Dix-Hallpike maneuver is the gold standard for diagnosing posterior canal BPPV. During this test, the patient moves from a sitting to a supine position with the head turned to one side and extended backward. A positive test elicits vertigo and characteristic nystagmus—torsional and upbeating—that subsides within seconds.

Therapeutic Maneuvers in Chiropractic Neurology

Chiropractic neurologists employ specific repositioning maneuvers to treat BPPV, aiming to relocate dislodged otoconia from the semicircular canals back to the utricle, alleviating vertigo symptoms. Key maneuvers include:

  1. Epley Maneuver: This involves sequential head and body movements to guide otoconia out of the posterior canal. The patient starts seated, turns the head 45 degrees toward the affected side, then lies back quickly with the head hanging. After holding this position, the head is turned 90 degrees to the opposite side, followed by rolling onto that side, and finally returning to a sitting position.
  2. Reverse Epley Maneuver: A variation of the Epley maneuver, this technique is used when standard maneuvers are ineffective or when the otoconia are suspected to be in a different canal. It involves similar head and body movements but in a reversed sequence to address specific canalithiasis.
  3. Barbecue Roll (Lempert Maneuver): Primarily used for horizontal canal BPPV, this maneuver involves the patient lying supine and then rolling the head and body in a series of steps away from the affected ear, effectively “rolling” the otoconia out of the horizontal canal.

Age-Related Considerations

BPPV can affect individuals of all ages but is most prevalent in those over 60. The increased incidence in older adults may be due to age-related degeneration of the otolithic membrane, leading to a higher likelihood of otoconia dislodgement. Additionally, older patients may experience more severe symptoms and have a higher recurrence rate, possibly due to concurrent age-related balance issues.

Potential Causes of BPPV

While BPPV often occurs idiopathically, several factors may contribute to its development:

  • Head Trauma: Injury can dislodge otoconia, leading to BPPV.
  • Inner Ear Disorders: Conditions like Ménière’s disease may increase the risk of BPPV.
  • Prolonged Bed Rest: Extended periods of immobility can lead to otoconia displacement.
  • Age-Related Degeneration: Degenerative changes in the inner ear structures can predispose individuals to BPPV.

The Connection Between Head Trauma and BPPV

Head trauma, including concussions and mild traumatic brain injuries (mTBI), is a well-documented cause of benign paroxysmal positional vertigo (BPPV). In fact, studies suggest that post-traumatic BPPV accounts for approximately 15–30% of all BPPV cases, making it one of the most common vestibular disorders following head injury (Hoffer et al., 2004; Kristiansen et al., 2021). Unlike idiopathic BPPV, which primarily affects older adults, post-traumatic BPPV can occur at any age due to the mechanical impact on the inner ear structures during head trauma.

Why Is BPPV More Common After Head Trauma?

  1. Otoconia Displacement Due to Impact Forces
    The otoconia (calcium carbonate crystals) in the utricle are particularly vulnerable to sudden mechanical forces. A blow to the head—whether from a fall, sports injury, motor vehicle accident, or concussion—can cause shearing forces within the inner ear. This dislodges the otoconia, which then migrate into the semicircular canals, disrupting normal vestibular function and leading to positional vertigo.
  2. Multiple Canal Involvement
    While idiopathic BPPV predominantly affects the posterior canal, post-traumatic cases often involve multiple semicircular canals (posterior, horizontal, or anterior). This can make the symptoms more persistent, severe, and difficult to treat, sometimes requiring multiple repositioning maneuvers to resolve (Hoffer et al., 2004).
  3. Increased Recurrence Rate
    Studies have found that BPPV after head trauma has a higher recurrence rate than idiopathic BPPV. This is likely due to residual vestibular dysfunction, incomplete resolution of canalithiasis, or ongoing instability of the otolithic structures. Patients with a history of concussion may experience repeated episodes of BPPV over time, requiring long-term vestibular management.
  4. Central Vestibular Dysfunction and Post-Concussion Syndrome
    Head trauma can also affect the central vestibular system, particularly the brainstem and cerebellum, which are critical for processing balance and spatial orientation. Some patients with concussions experience both peripheral (BPPV) and central vestibular dysfunction, leading to prolonged dizziness, imbalance, and difficulty with visual-vestibular integration. This dual involvement explains why some patients with post-traumatic BPPV have symptoms that are more persistent and complex than those with idiopathic BPPV (Kristiansen et al., 2021).

Diagnosis and Treatment Considerations in Post-Traumatic BPPV

  • More Comprehensive Vestibular Testing: Since head trauma can cause both BPPV and central vestibular dysfunction, a thorough vestibular examination, including Dix-Hallpike maneuver, horizontal roll testing, and videonystagmography (VNG), is often needed to differentiate between conditions.
  • Higher Need for Repeated Repositioning Maneuvers: Because multiple canals may be affected, more repositioning maneuvers (such as the Epley maneuver, Barbecue Roll, or modified techniques) are typically required compared to idiopathic BPPV.
  • Vestibular Rehabilitation Therapy (VRT): Many post-concussion patients benefit from vestibular rehabilitation, which includes gaze stabilization, balance training, and habituation exercises to address lingering dizziness and motion sensitivity.
  • Longer Recovery Time: Unlike idiopathic BPPV, which often resolves quickly with canalith repositioning, post-traumatic BPPV may require weeks to months for full resolution due to underlying central dysfunction or recurrent otoconia displacement.

Conclusion

BPPV is more common than not following head trauma, with a higher likelihood of multiple canal involvement, recurrence, and prolonged recovery. Understanding the link between concussions and BPPV is crucial for effective diagnosis and treatment, particularly in chiropractic neurology and vestibular rehabilitation settings. Tailored treatment approaches, including vestibular exercises and repositioning maneuvers, are essential for helping post-traumatic BPPV patients regain balance and reduce symptoms.

Chiropractic Neurology Treatment Options

Chiropractic neurologists focus on non-invasive, drug-free treatments to manage BPPV, emphasizing patient-specific therapeutic maneuvers and vestibular rehabilitation:

  • Vestibular Rehabilitation Therapy (VRT): Customized exercises aim to improve balance and reduce dizziness by promoting central nervous system compensation for vestibular deficits.
  • Patient Education: Educating patients about BPPV, its triggers, and preventive strategies is crucial for effective management and reducing recurrence.
  • Lifestyle Modifications: Advising patients on modifying daily activities to avoid provoking positions can help manage symptoms.

If you or someone you love is suffering from tremors and you would like to learn how chiropractic neurology can help, contact the team at Georgia Chiropractic Neurology Center today. We look forward to hearing from you.

Written by Sophie Hose, DC, MS, DACNB, CCSP

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