Take Back Control of Vertigo: BPPV Assessment & Treatment

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness, and a thorough BPPV assessment is critical to determine the appropriate maneuvers and develop an effective treatment plan for patients experiencing BPPV. In this article, we’ll review techniques for a comprehensive BPPV assessment and provide treatment tips for each BPPV type, including maneuvers you can assign using the Medbridge HEP Builder.

Understanding BPPV and its assessment

BPPV assessment starts by identifying the affected canal: posterior, anterior, or horizontal. This step is crucial because treatment approaches vary significantly depending on the type. To assess your patient, perform the following tests:

Dix Hallpike

Assess for posterior and anterior canal BPPV using maneuvers such as Left Modified Dix Hallpike with Pillows (see below) and Right Modified Dix Hallpike with Pillows.

Before instructing your patient to perform these tests at home, check for the following:

• They do not have serious neck pathology.
• They demonstrate a high enough cognitive level and motor control to successfully sequence movements correctly.
• They know to always have another person present to ensure they don’t injure themselves.

To perform this exercise in the clinic, hold and guide the patient’s head to hang over the edge of the treatment table.

The presence of up- and torsional-beating nystagmus toward the affected ear is indicative of posterior canal BPPV. For example, right posterior canal BPPV will display up beating with a right torsional eye movement. It is possible that only up-beating nystagmus is present. During a thorough BPPV assessment, focus on identifying the side that elicits the strongest vertigo or nystagmus, as this side should be treated.

The presence of down-beating nystagmus indicates anterior canal BPPV, which can be with and without a torsional component. For example, left anterior canal BPPV can be present with only down beating or down beating with left torsional nystagmus. A proper BPPV assessment helps confirm the affected side. When you only see down beating with no torsional component, treat the ear that elicits the strongest vertigo response from the patient.

Supine roll test

Assess for horizontal canal BPPV as part of a comprehensive BPPV assessment. To perform this test, the patient should be in a supine position with head resting on a pillow. Turn the patient’s head 90 degrees to the left and then right while observing the patient’s eyes.

The presence of horizontal, left to right, nystagmus is consistent with horizontal canal BPPV.

There are two variations of horizontal nystagmus you may encounter:

• Geotropic: Eyes beat toward the ground.
  • For example, when the patient’s head is turned to the right you would see right-beating nystagmus. This indicates canalithiasis—crystals or otoconia are freely floating in the canal.
  • You should treat the ear that elicits the greatest vertigo response from the patient, or the side that displays the strongest nystagmus in terms of duration and speed of eye movement.
• Apogeotropic: Eyes beat toward the ceiling.
  • For example, when the patient’s head is turned to the left you would see right-beating nystagmus. This rare form of nystagmus is cupulolithiasis—crystals or otoconia are stuck to the cupola, a structure located just outside the semicircular canals.
  • You may need to refer these patients to a vestibular specialist as treatment requires specific, advanced maneuvers. The specialist should treat the ear that elicits the weakest vertigo response from the patient, or the side that displays the weakest nystagmus in terms of duration and speed of eye movement.

BPPV treatment

Once your BPPV assessment has determined the type of nystagmus and localized which ear is affected, you can select the appropriate maneuvers from Medbridge’s HEP Builder. If patients consistently experience the same type of BPPV, it can be very helpful for the patient to treat themselves at home, but choosing the right maneuver can be tricky.

Below are some maneuvers to add to your patients’ programs according to the type of nystagmus being treated:

• Posterior canal:
  • Self-Epley Maneuver Left Ear
  • Self-Epley Maneuver Right Ear (see below)
  • Left Liberatory (Semont) Maneuver
  • Right Liberatory (Semont) Maneuver
    • Because this maneuver requires quick movements that can be more symptomatic, your patient should only perform it if the Self-Epley Maneuvers are not working.
  • Half Somersault Maneuver
    • This maneuver is specifically designed for patients to perform at home independently.

• Horizontal canal geotropic nystagmus:
  • Left Gufoni Maneuver for Horizontal Canal Canalithiasis
  • Right Gufoni Maneuver for Horizontal Canal Canalithiasis
  • Left 270 Degree Roll
  • Right 270 Degree Roll
    • It is your preference whether to use the Gufoni or 270 roll for treating horizontal canalithiasis. Both maneuvers have similar efficacy. Many clinicians prefer the Gufoni maneuver as it requires less steps for the provider and patient and is often utilized when the patient has mobility issues such as obesity or spinal stiffness.
• Horizontal canal apogeotropic nystagmus: Eyes beat toward the ceiling.
  • Left Gufoni Maneuver for Horizontal Canal Cupulolithiasis
  • Right Gufoni Maneuver for Horizontal Canal Cupulolithiasis
• Anterior canal: This form of BPPV is extremely rare, accounting for only 1 percent of BPPV cases.¹ Perform screening for central causes, which may also cause vertical nystagmus. If the patient’s BPPV is not responding after one to two treatment sessions, reconsider a possible referral if other central signs are present or re-evaluate to see if other causes such as concussion or cervicogenic (neck) dizziness are the culprit.
  • Short Canal Repositioning Maneuver
    • To perform this maneuver, begin with the patient in a seated position with the head turned 45 degrees toward the affected ear. Have the patient lay back maintaining the 45 degree head turn with the head hanging 40 degrees below the table. While in this head hanging position turn the head 45 degrees to the non affected side. Finally sit the patient up and keep the head turned 45 degrees to the non affected side. Once the patient is fully upright, return head to center. Maintain each position for 1 minute or until vertigo fully resolves.

Incorporating these maneuvers in your practice can help your patients alleviate their BPPV symptoms and improve their quality of life.

Strengthening your practice with accurate BPPV assessment

A comprehensive BPPV assessment is more than just identifying the affected canal and prescribing treatment; it’s an opportunity to transform the way patients experience and manage their vertigo. Effective assessment goes beyond alleviating symptoms—it helps build patient confidence, fosters independence in managing recurring episodes, and ensures a deeper understanding of their condition.

By refining your clinical skills with tools like the Dix-Hallpike and Supine Roll tests, and leveraging resources such as Medbridge’s HEP Builder, you can create a more personalized care plan tailored to each patient’s unique needs. Furthermore, integrating patient education into the process empowers individuals to take proactive steps, whether through at-home maneuvers or knowing when to seek professional help.

Ultimately, a well-executed BPPV assessment doesn’t just resolve vertigo; it enhances the patient’s quality of life, equipping them with the knowledge and strategies to minimize disruption and regain control over their daily activities. As a clinician, this holistic approach ensures your practice remains patient-centered and impactful.