What exercises can help manage Benign Paroxysmal Positional Vertigo (BPPV)?

Exercises for Managing Benign Paroxysmal Positional Vertigo (BPPV)

The Canalith Repositioning Procedure (Epley maneuver) is the most effective treatment for posterior canal BPPV, with success rates of 61-95% after a single treatment and significantly better outcomes than sham procedures or no treatment. 1, 2

Types of Repositioning Maneuvers for BPPV

For Posterior Canal BPPV (most common type):

1. Canalith Repositioning Procedure (Epley Maneuver)

   • Most effective first-line treatment
   • Success rate of 90.7% after initial maneuver, increasing to 96% after second attempt 3
   • 6.5 times greater chance of symptom improvement compared to controls 1
   • Steps:
     • Patient moves from sitting to lying with head extended and turned 45° toward affected ear
     • Head is then rotated 90° to opposite side
     • Body and head rotate another 90° until nearly face-down
     • Patient returns to sitting position

2. Liberatory (Semont) Maneuver

   • Alternative to Epley with comparable effectiveness
   • Involves rapid movement through 180° arc
   • May be preferred for patients with mobility limitations

For Lateral (Horizontal) Canal BPPV:

1. Gufoni Maneuver

   • For geotropic type: 93% success rate 1
   • For apogeotropic type: Specific variation needed
   • Steps vary based on type (see tables 14 and 15 in guidelines) 1

2. Barbecue Roll Maneuver (Lempert)

   • Alternative for lateral canal BPPV
   • 75-90% effectiveness based on case series 1

Self-Administered Options

• Self-administered Epley: 64% improvement rate
• Self-administered Semont: Less effective than self-Epley (58% vs 95% resolution) 1
• Brandt-Daroff exercises: Less effective than Epley (23% vs 64% improvement) 1
  • A single Epley treatment is >10 times more effective than a week of Brandt-Daroff exercises 1, 4

Important Clinical Considerations

• No post-procedural restrictions needed after Epley maneuver (strong recommendation) 1
• Diagnostic confirmation is essential before treatment:
  • Dix-Hallpike test for posterior canal BPPV
  • Supine roll test for horizontal canal BPPV 2
• Recurrence rate is approximately 36% within the first year 2, 4
• Adverse effects are generally mild:
  • Nausea during repositioning (16.7-32%)
  • No serious adverse effects reported 4
  • Some patients with cervical spine problems may not tolerate the maneuvers 4

Special Situations

• Secondary BPPV (due to trauma, surgery, etc.) has lower success rates with repositioning maneuvers 3
• Elderly patients may require modified techniques but should still receive repositioning maneuvers 2
• Persistent symptoms after multiple maneuvers may indicate:
  • Multiple canal involvement
  • Associated comorbidities (migraine, persistent postural perceptual dizziness)
  • Low vitamin D levels 5

When Repositioning Maneuvers Fail

• Shortened Forced Position (SFP): For lateral canal BPPV, lying on the side where vertigo is less intense for 1 hour can resolve symptoms in 71.7% of patients 6
• Vestibular rehabilitation: Less effective than repositioning maneuvers but may help with chronic imbalance after acute BPPV resolves 2

Important Cautions

• The Epley maneuver is not appropriate for patients who experience dizziness only when closing their eyes but are stable with eyes open 2
• BPPV should be distinguished from central causes of vertigo using the HINTS examination when appropriate 2
• Vestibular suppressants should be limited to short-term use (<1 week) to avoid interfering with vestibular compensation 2

The evidence strongly supports using specific repositioning maneuvers as the primary treatment for BPPV, with the choice of maneuver depending on the affected canal and patient factors.