Effectiveness[ edit ] The Epley maneuver is a safe and effective treatment for BPPV, though the condition recurs in around one third of cases. The patient is then quickly lowered into a supine position with the head held approximately in a degree neck extension Dix-Hallpike position , with the head still rotated to the side. The patient remains in this position for approximately 1—2 minutes. Keeping the head and neck in a fixed position relative to the body, the individual rolls onto their shoulder, rotating the head another 90 degrees in the direction that they are facing. The patient is now looking downwards at a degree angle.
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Vertigo exercises Dix Hallpike and Epley maneuver Dix-Hallpike maneuver when properly employed can identify a common, benign cause of vertigo such as benign paroxysmal positional vertigo BPPV , which can then be treated with bedside maneuvers, often providing instant relief to patients 1. Vertigo is a sensation of movement or spinning, tilting, swaying or feeling unbalanced, which may be experienced as self-motion to some versus movement of the surrounding environment to others.
Vertigo feels like you or everything around you is spinning — enough to affect your balance. A vertigo attack can last from a few seconds to hours. If you have severe vertigo it can last for many days or months. Vertigo is more than just feeling dizzy. Vertigo can be of vestibular or peripheral origin or be due to non-vestibular or central causes.
With regards to peripheral vertigo, benign paroxysmal positional vertigo BPPV is the most common cause, accounting for over one-half of all cases. It is of great importance to identify benign paroxysmal positional vertigo BPPV versus other causes of vertigo as the differential diagnosis includes a spectrum of diseases processes ranging from benign to life-threatening 3.
Benign positional paroxysmal vertigo BPPV disease process is thought to be caused by free-floating debris often in the form of a calcium carbonate stones, termed otoliths or otoconia in the semicircular canals of the inner ear.
These otoconia are essential to proper functioning of the utricle of the otolithic membrane by helping deflect the hair cells within endolymph, which relays positional changes of the head including tilting, turning, and linear acceleration 4.
Benign positional paroxysmal vertigo is typically thought to be caused by dislodgement of a piece of calcium carbonate otoconia from the otoconial membrane within one of the canals, physically displacing hair cells on movement and creating persistent action potentials until the response is fatigued, generally within 30 to 60 seconds 5. This results in the sensation of movement and nystagmus characteristic of vertigo in brief paroxysms with positional changes of the head.
The Dix-Hallpike maneuver is the gold standard for diagnosing benign positional paroxysmal vertigo caused by a posterior canal otolith. The patient is positioned recumbent with the head back and toward the affected ear, causing the otolith to progress superiorly along the natural course of the canal.
Typically, after a five to second delay, this will cause vertigo and rotary or up-beating nystagmus, which will resolve within 60 seconds 6. Three canals make up this system, each forming a loop filled with endolymph and lined with hair cells see Figures 1 to 4. During normal rotational movement of the head, the fluid endolymph remains relatively motionless while the canals and the hair cells move. The hair cells are mechanically pushed by the resistance of the endolymph, opening mechanically gated ion channels that trigger an action potential indicating rotational movement.
Each of the three canals is oriented slightly differently, with the anterior and posterior canals in the vertical plane, set to detect movement in the sagittal and coronal planes, respectively, and the lateral canal 30 degrees off from the horizontal plane, detecting movement to the left or right in the horizontal plane 7.
The Dix-Hallpike maneuver is the gold standard for diagnosis of benign positional paroxysmal vertigo, so it is difficult to assess its sensitivity and specificity acutely. Once these causes have been ruled out, if benign positional paroxysmal vertigo is on the differential, the Dix-Hallpike maneuver can diagnose the problem. This can be readily transitioned into the Epley maneuver, in which the position of the otolith continues to be manipulated until it is out of the posterior canal, ending the sensation of vertigo with positional changes and curing the disease process.
While there is a high rate of recurrence and this is not always effective, relieving the symptoms of our patients in this way is highly desirable, and patients can be given instructions on how to do this at home for recurrences 8. When to see a doctor Go to the emergency department if you have vertigo and: double vision or loss of vision hearing loss leg or arm weakness, numbness or tingling an inability to walk without assistance passing out chest pain vomiting that will not stop Always take someone who has lost consciousness to the emergency department or call your local emergency services number.
This 20 degrees of extension may either be achieved by having the clinician supporting the head as it hangs off the table or by placing a pillow under their upper back. Fatigues is when the nystagmus progressively weakens when the test is repeated. If the response fatigues, the patient has confirmed BPPV.
If the nystagmus does NOT fatigue, it suggests a problem other than the inner ear ie, brain or spine , most commonly cervicogenic vertigo is present. In this situation, seeing a neurologist or potentially a spine surgeon is the next appropriate step to evaluate the dizziness further.
Something else is causing the dizziness. If the test is negative but clinical suspicion remains high, the patient should be given a chance to recover for at least one minute, and then testing of the other ear can be undertaken. Lateral canal pathology may not be detected by this method, and a supine roll test may be done if this is suspected 9.
The affected ear is the side that the head is turned to that causes the nystagmus to occur. Nausea and vomiting are common during Dix Hallpike maneuver; this can potentially be avoided by giving an antiemetic before testing Treatment is the Epley maneuver.
Watch the video above and below that demonstrates the Epley maneuver for a patient whose right ear is affected. For patients in which the left ear is affected, the Epley is performed the opposite direction with the head first turned to the left. An alternative maneuver to the Epley is the Foster Half-Somersault.
Alternatively, you can purchase a device called DizzyFIX that ensure you do the Epley maneuver correctly. If Dix-Hallpike produces Side-to-Side Lateral nystagmus When the Dix-Hallpike is performed and a patient exhibits a side-to-side nystagmus that weakens with repeated maneuvers, the patient most likely is suffering from lateral or horizontal canal BPPV.
With lateral canal BPPV, the nystagmus can be either always towards the ground geotropic or always towards the sky ageotropic. The direction is determined by the direction of the fast eye twitch. With ageotropic nystagmus, the bad ear is assigned to the side with the weaker nystagmus. Watch the video below that demonstrates the Lempert maneuver for a patient whose right ear is affected.
For patients in which the left ear is affected, the Lempert is performed the opposite direction with the head first turned to the left and rolling to the right. This is very different than posterior canal BPPV where one is typically dizzy when turning the head to look over the shoulder or rolling over in bed.
Treatment is the Deep Head-Hanging maneuver. Watch the video below that demonstrates this maneuver for a patient with superior canal BPPV. When it does not fatigue, it argues against BPPV and suggests either a brain or spine issue, most commonly cervicogenic vertigo is present. These patients experience vertigo in brief episodes lasting less than one minute with changes of head position and return to total normalcy between episodes. Light-headedness or a sensation of nausea might last longer than one minute, but if the sensation of movement persists for more than one-minute alternative diagnoses must be considered.
Dizziness is a common complaint, and serious causes must be considered and excluded first. Non-paroxysmal vertigo is more likely to be caused by a vestibular syndrome or central etiology, such as brainstem stroke Any neurological deficit, especially truncal ataxia, should generate concern for a central cause and trigger further workup.
If the history is consistent with benign positional paroxysmal vertigo, the Dix-Hallpike maneuver is the test of choice for diagnosis The patient may have a small corrective saccade. The head impulse test is positive consistent with peripheral vertigo if there is a significant lag with corrective saccades. If you can see the correction, it is abnormal.
Compare this to the contralateral side; a difference in the speed of correction should be noted. The horizontal head impulse test is consistent with peripheral vertigo if it is positive in one direction only. If there is a lag in corrective saccades in both directions, it may be concerning for central vertigo. This test can also be performed in the vertical plane. A lag in corrective saccades in the vertical plane is always suspicious for a central etiology for vertigo.
Pitfalls: The patient must be awake and cooperative. Patients who are mentally impaired, unable to fixate, or sedated cannot do this maneuver. Likewise, anxious patients who are unable to relax their neck are unable to do this procedure adequately. False negatives often result from an inexperienced practitioner being too gentle with the head thrust due to fear of causing neck injury.
Contraindications: Any patient that has head trauma, neck trauma, an unstable spine, or neck pain concerning for arterial dissection. This maneuver may extend the injury. In addition, one should avoid this in patients with known severe carotid stenosis as it may embolize unstable plaque.
An acceptable alternative is assessing for ocular dysmetria. Nystagmus Note if it is present in primary gaze i. What direction is the fast component? If the nystagmus is worse looking in one direction, with the fast component present in that same direction on contralateral gaze, it is unidirectional and reassuring for peripheral vertigo.
If, for example, a patient has right-beating fast direction to the right nystagmus with rightward gaze and leftward gaze, this is unidirectional right-beating nystagmus. The most common peripheral nystagmus, BPPV, in the posterior semicircular canal consists of a unidirectional horizontal nystagmus with a torsional component. Bidirectional nystagmus, that is fast component to the right with rightward gaze and to the left with leftward gaze, is concerning for a central process, as is vertical nystagmus or pure torsional nystagmus.
A positive result will be the deviation of one eye while it is being covered, followed by correction after uncovering it. Dix Hallpike maneuver contraindications The Dix-Hallpike maneuver should be avoided in a patient with neck pathology, in whom the movements involved could be dangerous to the patient. Cervical instability, vascular problems like vertebrobasilar insufficiency and carotid sinus syncope, acute neck trauma and cervical disc prolapse are absolute contraindications.
In patients without an absolute contraindication, one paper suggests briefly assessing neck rotation and extension before attempting the maneuver to see if these positions can be comfortably maintained for thirty seconds Benign paroxysmal positional vertigo Benign paroxysmal positional vertigo BPPV is a problem with the inner ear. Benign paroxysmal positional vertigo occurs when small pieces of bone-like calcium carbonate crystals or otoconia canaliths break free and float inside small canals in your inner ear see Figure 3.
Benign paroxysmal positional vertigo BPPV causes you to suddenly feel dizzy. Benign paroxysmal positional vertigo is the most common type of vertigo. Benign paroxysmal positional vertigo is also the easiest to treat. Vertigo is a sensation of movement or spinning, tilting or swaying. With benign paroxysmal positional vertigo you might feel like the room is spinning around in circles or that your surroundings are moving.
Benign paroxysmal positional vertigo is associated with feelings of vertigo when you move a certain way. This could be when you turn your head, stand up, roll over in bed, or lie down. You might also feel nauseated at the same time. The nausea and dizziness usually go away in a few seconds. The only thing you can do to prevent or avoid benign paroxysmal positional vertigo is to avoid head positions that trigger it.
BPPV is fairly common, with an estimated incidence of per , per year2 and a lifetime prevalence of 2. Benign paroxysmal positional vertigo BPPV most often affects older adults with a peak age of onset in the sixth decade Benign paroxysmal positional vertigo BPPV may affect individuals of any age, but is quite uncommon in those under 20 years of age. Women are believed to be affected at least twice as often as men.
The vast majority of cases occur for no apparent reason, with many people describing that they simply went to get out of bed one morning and the room started to spin.
Can you see through these real-life optical illusions? A Hallpike maneuver, also known as a Dix-Hallpike test, is a medical test that a doctor may perform on a patient who has dizziness or vertigo. Patients with dizziness may undergo a series of tests during a medical examination. During a Hallpike maneuver, a patient usually sits on a table. Patients often develop dizziness and nystagmus very quickly from this maneuver if they have an inner ear disorder. Nystagmus is an involuntary eye movement that generally causes fast movement of the eyes in one direction alternating with a smoother eye movement in the other direction.
Procedure[ edit ] When performing the Dix—Hallpike test, patients are lowered quickly to a supine position lying horizontally with the face and torso facing up with the neck extended 30 degrees below horizontal by the clinician performing the maneuver. As such, the side-lying position can be used if the Dix—Hallpike cannot be performed easily. In BPPV, the nystagmus typically occurs in A or B only, and is torsional--the fast phase beating towards the lower ear. Its onset is usually delayed a few seconds, and it lasts seconds. As the patient is returned to the upright position, transient nystagmus may occur in the opposite direction.
Dix Hallpike maneuver