Benign Paroxysmal Positional Vertigo

Bppv pattern header

Body Chart

Bppv body chart

Background Information

Patient Profile

  • Most common form of vertigo (19%)
  • 90% posterior canal, 10% horizontal canal
  • 1 in 3 affected before 7th decade
  • 2/3 female
  • Yearly incidence 10-20:100.000



Otolith particles break off of the macula utriculi and accumulate in the posterior (90%) and horizontal (10%) canal. They accumulate at the lowest point of the canal. Movement of otolith particles during e.g. head rotation cause vertigo and nystagmus


  • Head trauma (~20%)
  • Neurolabyrinthitis (10- 15%)
  • Migraine
  • Prolonged bedridden period
  • Genetic predisposition


Very good prognosis. ~90% symptom free after one maneuver. If strategy is executed properly, success rate of ~100%. If maneuver was done successfully, discomfort subsides within a week. Relapse rate 2-5%

History & Physical Examination


Head trauma, migraines, bedridden for extended period, inner ear pathology

  • Possibly associated neck pain
  • Real vertigo:
    • Illusionary sensation of movement (own body, surroundings)
    • Tilt of visual surroundings
    • Rotational
  • Nystagmus with rotation
  • Lateropulsion
  • Feeling of falling or lifting
  • No neurological symptom character
  • Associated reactions:
    • Vertigo
    • Vomiting
    • Fainting
    • Ataxia
    • Hearing problems/Tinnitus

Physical Examination

Active Examination
Neck movement is avoided and leads to AROM limitation

Functional Assessment
Change of head position triggers nystagmus and vertigo

Special Testing

Differential Diagnosis

  1. Infection
  2. Intoxication
  3. Tumor
  4. Idiopathic
  5. Psychogenic
  6. Metabolic
  7. Phobia
Bppv flowchart



Maneuvers are very effective. Patient education and instructions on behavior at home are incorporated



  • Maneuver is only then positive if dizziness occurs. Therefore, hold the position.
  • After symptoms subside, patients should remain in the end position for ~4min to prevent particles from returning back
  • Beware of sudden retropulsion
  • In case maneuver fails, wait at least 10 min before trying again
  • Max. 3 consecutive tries

Home instructions

  • Patients may experience discomfort within the next 24h (normal reaction of CNS)
  • No sudden head movements
  • Avoid lying on affected side
  • In supine, use a pillow under neck to avoid hyper extension
  • Lying prone and on unaffected side is permitted
  • Adapted Epley maneuver as self-help tool

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  1. Epley, J. M. (1992). The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg, 107(3), 399-404.
  2. Hauswirth, J. (2008). zervikogener Schwindel: Diagnose und manualtherapeutische Behandlung. (12), 80-93. doi:10.1055/s-2008- 1027384
  3. Oostendorp, Eupen, v., Erp, v. (1999). Dizziness following whiplash injury: a neurootological study in manual therapy practice and therapeutic implication. The Journal of Manual and Manipulative Therapy, 7, 123-130.
  4. Reid, S. A., Rivett, D. A., Katekar, M. G.,  Callister, R. (2014). Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial. Phys Ther, 94(4), 466-476. doi:10.2522/ptj.20120483
  5. Schmäl, F. (2005). Benigner paroxysmaler Lagerungsschwindel. In W. M (Ed.), Vestibularfunktion: Brücke zwischen Forschung und Praxis.
  6. Semont, A., Freyss, G., Vitte, E. (1988). Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol, 42, 290-293.
  7. Sloane, P. D., Coeytaux, R. R., Beck, R. S., Dallara, J. (2001). Dizziness: state of the science. Ann Intern Med, 134(9 Pt 2), 823-832.
  8. Stoll, W., Most, E., Tegenthoff, M. (2004). Benigner Paroxysmaler Lagerungsschwindel. In W. Stoll (Ed.), Schwindel und Gleichgewichtsstörungen (Vol. 4, pp. 141-146). Stuttgard: Thieme Verlag.
  9. Wiemer, M. (2011). Benigner paroxysmaler Lagerungsschwindel (BPLS). Manuelle Therapie, 15, 172-177. doi:dx.doi.org/10.1055/s-0031- 1281694Wrisley, D. M., Sparto, P. J., Whitney, S. L., & Furman, J. M. (2000). Cervicogenic dizziness: a review of diagnosis and treatment. J Orthop Sports Phys Ther, 30(12), 755-766. doi:10.2519/jospt.2000.30.12.755
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