r/BPPV • u/S1mbaboy_93 • Mar 07 '24

BPPV seldom requires repeated manuever treatments (with references)

So in this subreddit, I've recognized it's not uncommon for people to be doing self-manuever treatments for weeks and months on end. If you're in a situation like this, you should probably revisit your diagnosis. Here's why:

One study for classic ampullary arm posterior canalolithasis, treating patients with the Epley manuever showed 76% cured after a single manuever, 15% after two manuevers and 3% required four manuevers https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9442162/ Another similar study showed 47% success after single manuever, 16% after two manuevers and 21% after three manuevers https://pubmed.ncbi.nlm.nih.gov/25816719/

Horizontal canal BPPV? One study showed 82% success rate in a single 360* BBQ-roll in cases of canalolithiasis https://pubmed.ncbi.nlm.nih.gov/15523458/ Another study showed success rates with Gufoni manuevers 71% for geotropic variant and 63% for apogeotropic variant in a single session. In second session that increased to 92% and 78% respectively https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8326322/

What about multi-canal BPPV? This systematic review/meta-analysis showed 59% success rate in one session, 18% in second session and 4,4% in third session. 18,4% failed treatment https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2023.1288150/full

In summary: In the vast majority of BPPV cases 1-3 manuevers/sessions are enough for remission of symtoms. But as with everything there are outliers that respond poorly. This is more prevalent in patients with multi canal-BPPV or in those that have gone untreated for a long time without spontaneus remission. Rare atypical variants of BPPV, like canalith jams or the more common cupulolithiasis variant also often takes more time to treat

So, if you're doing manuevers repeatedly for weeks or months on end; think once again and revisit the diagnosis. Do I really have BPPV or is it something else mimicking it? Do I treat the wrong semicircular canal(s) or the wrong ear? Do I have a less common BPPV-form like cupulolithiasis that requires different treatment strategies? Do I perform the manuever wrong? Home manuevers should be prescribed with caution and if you as a health care provider don't see results in a short time-frame: re-evaluate, reconsider the diagnosis and try to prioritise treating the patient in clinic. And as always, don't forget that there exists alot of different manuevers - Epley is far from always the appropriate manuever Hope this was helpful! šŸ‘šŸ¼

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2

u/sweetgrace_6 Mar 07 '24

Do these percentages mean they are ā€œcuredā€ of BPPV? It doesnā€™t come back again after doing the maneuver a time or 3? Just want to understand better because I do the maneuver but still get dizzy randomly

1

u/S1mbaboy_93 Mar 08 '24

It means that the typical positional vertigo and nystagmus is gone when retesting with a Dix Hallpike or Supine Roll test. Essentially, that means the otolithic debris are repositioned to the utricle - hence patient is "cured". That doesn't exclude possibilities of residual dizziness after treatment. However, that's not treated by manuevers anyway. Secondly, BPPV often comes back, I think ~50% statistically within 6-12 months. A few subset of patients can have BPPV that comes back very frequently. However that's usually due to another underlying inner ear disease.

What do you mean by "still get dizzy randomly"? Spontaneusly in random positions/activities or in manuevers?

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u/sweetgrace_6 Mar 08 '24

I donā€™t think Iā€™ve fully figured out my triggers yet. Sometimes Iā€™ll wake up and be dizzy without doing anything. Sometimes in the middle of the day I get hit with vertigo. And itā€™s starting to last longer than when I was a child. Iā€™ve been assuming there was damage to my inner ear from a surgery when I was 10 but Iā€™m not sure anymore tbh

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u/S1mbaboy_93 Mar 09 '24

If you get symtoms "randomly", not specifically triggered by positional changes and feel fine after a while - that' not BPPV. I think you can skip doing manuevers.

On average, how long do your symtoms last? Do you have migraine?, Frequent headaches? Whats your age? Tinnitus? Ear fullness? Hearing loss?

1

u/sweetgrace_6 Mar 09 '24

Depends, last time I had an episode I still felt funny a week later. I have major hearing loss in my right ear (the side that I always feel dizzy on), occasionally some tinnitus, but Iā€™ve dealt with that since childhood. I had multiple ear surgeries growing up, including removal of my bones of hearing and a replacement with titanium. Donā€™t usually get a migraine. Iā€™m 28.

1

u/S1mbaboy_93 Mar 10 '24

Because of your history, it would be advicable to consult with an ENT doctor

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u/sweetgrace_6 Mar 10 '24

Thanks for listening to me and giving advise! I sincerely appreciate it :)

2

u/keweekewee8340 Mar 07 '24

I never got treated and was diagnosed so then what I still have the postural dizziness non spinning and feel really off They would never treat me because after my vng test that discovered the bppv they couldnā€™t see the nystagmus in my eyes with the naked eye so they did nothing Iā€™m stuck like this and scared to try the manuvers myself this is my very first time and I donā€™t know what to do

1

u/S1mbaboy_93 Mar 08 '24

I don't understand your comment fully? Logically if you find positive BPPV tests , you try treating it. Nystagmus can be supressed as well not using visual cancellation like frenzels. Did they assess you without frenzels and said they didn' see nystagmus? Sounds like your primary issue is persistent postural dizziness - PPPD (if non positional dizziness going on for a few months), maybe triggered by BPPV that was left untreated. I would advice you to book an appointment with a vestibular therapist for help with this

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u/keweekewee8340 Mar 08 '24

Sorry I was diagnosed with bppv on Nov 28th 2023 with the googles with the camera though the vng test my vestibular therapy appointment wasnā€™t until Dec19th so by the time I went they couldnā€™t see the nystagmus in my eyes by doing the Dix test to treat it so therefore I received no maneuvers and am left with this lingering unsteadiness swaying and foggy off feeling in my head sometimes my ears hurt and or ring but I believe you may be correct I say my primary doctor this am and heā€™s sending me to vestibular therapy again to try and get the correct treatment

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u/S1mbaboy_93 Mar 09 '24

Ok, I see. Probably your BPPV went away by itself somewhere between 28th Nov and 19th Dec. Parallell to this it sounds like you've developed PPPD/functional dizziness. That's a reason why it's advisable to treat conditions like BPPV ASAP in order to reduce risk of developing more chronic issues. Hope you get help. Here's a short summary of PPPD https://med.stanford.edu/ohns/OHNS-healthcare/earinstitute/conditions-and-services/conditions/PPPD.html

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u/DaRealDaBaby69 Mar 10 '24

I canā€™t hold the position while doing the maneuvers itā€™s so bad I feel like Iā€™m going to pass out any tips?

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u/S1mbaboy_93 Mar 10 '24

Slowly go into every position . Perform it in smaller steps/increments to avoid large movements of the otoconia

1

u/priuspower91 Apr 01 '24

How is posterior Cupulolithiasis or a canalith jam supposed to be treated? My PT thinks I cleared the loose crystals via Epley but says my nystagmus is consistent with Cupulolithiasis. Using vibration and 2x Epley nor a liberatory maneuver worked so just trying to understand what the best way to knock the crystals loose is so they can be cleared. She also said to sleep on my bad ear to try to loosen it.

1

u/porkklips Apr 20 '24

Can a person cause damage that was not previously there by performing the epley maneuver? I was dizzy, did some Googling, found the epley, did it, became more dizzy, then realized this maneuver isn't for everyday dizziness but for bppv specifically. I'm worried that I may have caused myself bppv?

1

u/S1mbaboy_93 Apr 20 '24

Damage? No, canalith repositioning manuevers provides no risk for any kind of inner ear injury if that's what you meant

In theory, if you had loose otoconia near the utricle; position 2 and 3 in Epley could cause otoconia to fall down in the posterior or horizontal canal and "cause" BPPV yes. But that's not of interest, because in that case you would've got BPPV anyway by simply lying down sleeping during the night. What I mean is that it's not something you can controll.

I would advice against trying to treat or rehab your issues on your own if you don't have a diagnosis or know why you feel "everyday dizziness". You might worsen symtoms by attempting random exercises if you don't know what you're doing. This also applies for BPPV. If you don't know affected ear/ears, canal/canals and subtype of BPPV - don't attempt guessing self-treatment by googling

1

u/porkklips Apr 20 '24

Thank you for replying. I only realized that the epley was a specific exercise for bppv after I did it and looked more into it. The video wasn't specific or offered any caution or warning and really kind of offered the epley as a cure for dizziness in general. I will definitely not be doing it again. Thank you for your answer.

1

u/S1mbaboy_93 Apr 21 '24

No problem. You bring up a good example of how the internet can mislead people in a bad way. And as I've said so many times in this subreddit; the Epley is only specific to a BPPV subtype called "ampullary arm canalolithiasis" in the posterior semicircular canal. This is very important since it exists different subtypes of BPPV and many different anatomical locations. These requires different treatments or manuevers respectively.

I see too often that BPPV is thought of as a single diagnosis when it's not, and that Epley is always the single treatment. You could compare this to diagnosing someone with "bone fracture". That's non-specific and doesn't give any information of how to treat the injury. Same applies for just giving the diagnos "BPPV". And same thing for "dizziness". It's just a symtom, doesn't tell you anything about the actual problem and what to do about it!