Dizziness has many varied origins and descriptions. Vertigo is the sensation of dizziness that feels like spinning. It does not matter whether the room spins or you spin. It’s vertigo either way. Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of inner ear dizziness. The spinning with this condition typically occurs when the person moves into or out of a lying down position, bends forward such as to tie a shoe, or tips back like rinsing hair in a shower. It can be startling and scary and may even cause a serious fall. It truly is benign, however, and easily treated.
The cause of BPPV is the dislodging and moving of calcium carbonate crystals, called otoconia, from one place to another in the inner ear. When these microscopic “rocks” move into the semicircular canals, they cause the nerve to be stimulated and the brain misinterprets that signal as spinning. Fortunately, the spinning usually lasts less than a minute. The nausea or imbalance, however, can last longer.
Otoconia normally function in the inner ear to assist with motion detection. They are located in the gravity sensors of the inner ear called the saccule and the utricle and are surrounded by fluid called endolymph. These ear crystals are primarily made of calcium carbonate and glycoproteins and connect to hair cells deep in the vestibular apparatus with protein fibers. When the head moves, thousands of crystals signal the nerves in a way that the brain knows things like the direction and speed the person is moving.
Most cases of BPPV have no known cause. Correlations have been found, though between this type of vertigo and concussion, whiplash, migraine, diabetes, and other ear pathologies such as Meniere’s Disease. Increasing recent evidence has implicated osteoporosis as a risk factor for BPPV. This is even more profound when osteoporosis co-exists with conditions such as high blood pressure, osteoarthritis, and diabetes.
Research is confirming strong correlations between low bone density and vitamin D levels, and BPPV. In one study, a 60% prevalence of osteoporosis and 76% prevalence of vitamin D deficiency was found among the patients with BPPV. Postmenopausal patients with BPPV had a significantly higher prevalence of vitamin D deficiency and osteoporosis. It has also been reported that BPPV affects women 2 times more often than men. Middle aged women account for a large percent of total cases of BPPV.
Recurrence of BPPV is a common problem. The recurrence rate is also significantly higher in women with osteoporosis compared to those with normal bone mass. It also has been found that the frequency of the recurrence increases as the bone density decreases.
We all know the risks and benefits of sunshine. Cautious exposure to the sun is one of the best sources of vitamin D. A study in the UK showed that vitamin D levels fell significantly in the winter, reaching its lowest levels in March and the highest in September. Another study found that the incidence of BPPV in Boston is higher between March and May.
It is well established that vitamin D and calcium are necessary for bone health. Bone mineralization and strength suffers in their absence. Vitamin D assists in the absorption of calcium. The ear crystals, which are made of calcium carbonate primarily, likewise, require adequate calcium and vitamin D for proper health.
Though BPPV can cause an awful feeling and can be very disruptive to daily mobility and productivity, the treatment is rather simple and typically has quite dramatic results. I find in my clinical practice as a vestibular physical therapist, that we can get rid of the vertigo in 1-2 visits in about 90% of those we see.
The vestibular specialist, first must determine where those ear crystals (otoconia) have landed. One of many varied canalith repositioning treatments (CRT) is chosen based on the particular location and characteristics of the BPPV. Other factors must be considered, such as any cervical limitations or medical precautions. The most common CRT is called the Epley maneuver. It is highly successful in the treatment of posterior canal BPPV. Another popular, but less studied maneuver is the Foster Half Summersault. Most of these procedures can be done at home; however, if done improperly, the dizziness can change or worsen. It is always best to find a specialist. I often train my clients how to do the maneuver which is best for their particular situation.
Those with recurrent refractory BPPV should be screened for both osteoporosis and vitamin D deficiency. The gold standard for the detection of osteoporosis and osteopenia is a DEXA scan. The most commonly accepted blood test for serum vitamin D is the 25 Hydroxy D.
Prevention and treatment of osteoporosis and low vitamin D levels center on nutrition. Vitamin D laden foods include fish and fish oils, egg yolks, fortified milk, and beef liver. Those high in calcium include dairy products, spinach and other leafy greens, and certain fish.
Weight bearing exercise and resistance training with weights can slow the progression of bone loss. Moderate exposure to sunlight, especially in winter months may reduce occurrence of BPPV. Supplementation of calcium and vitamin D is recommended for many and should be discussed with a physician.
Though Benign Paroxysmal Positional Vertigo cannot be completely prevented, these preventative measures can reduce the chance of acquiring it in the future. Fortunately, as well, highly successful treatment exists to minimize the suffering of those who do develop BPPV.
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