Understanding BPPV: How Vestibular Physiotherapy Can Help

If you’ve ever experienced a sudden spinning sensation when rolling over in bed or tilting your head back, you may have encountered Benign Paroxysmal Positional Vertigo, commonly known as BPPV. It’s one of the most common causes of vertigo, and the good news is that vestibular physiotherapy offers highly effective treatment.

What Is BPPV?

BPPV occurs when tiny calcium carbonate crystals called otoconia become dislodged from their normal location in the utricle (part of the inner ear) and migrate into the semicircular canals. These crystals are normally embedded in a gel-like structure where they help detect gravity and linear acceleration.

When these crystals end up in the semicircular canals—which are designed to detect rotational head movements—they create false signals to the brain. This mismatch between what your inner ear is telling your brain and what your eyes and body are sensing causes the characteristic spinning sensation of vertigo.

Common Symptoms of BPPV

• Brief episodes of intense spinning or dizziness lasting less than one minute
• Triggered by specific head movements (rolling over in bed, looking up, bending forward)
• Nausea or vomiting during episodes
• Unsteadiness or balance problems between episodes
• Nystagmus (involuntary eye movements) during vertigo episodes

Why Is BPPV More Common in Winter?

Research has shown an interesting connection between BPPV and vitamin D levels. Vitamin D plays a role in calcium metabolism, and lower levels may affect the stability of the otoconia in the inner ear. Since vitamin D is primarily synthesized through sun exposure, levels tend to drop during winter months, potentially contributing to increased BPPV occurrences during this season¹.

Studies have also found that vitamin D supplementation may help reduce recurrence rates in people with frequent BPPV episodes².

How Is BPPV Treated?

The primary treatment for BPPV is canalith repositioning maneuvers, which are specific head and body movements designed to guide the displaced crystals out of the semicircular canals and back to their proper location.

The Epley Maneuver

The most well-known and widely used treatment is the Epley maneuver, named after Dr. John Epley who developed it in 1980. This technique targets the posterior semicircular canal, where approximately 80-90% of BPPV cases occur³.

The Epley maneuver involves a specific sequence of head positions that use gravity to move the crystals through the canal and deposit them in the utricle where they can be safely reabsorbed. The procedure typically takes about 15-20 minutes.

Success rates are remarkably high:

• 70-80% of patients experience complete resolution after a single treatment
• 90-95% are symptom-free after 2-3 treatments
• Most patients feel immediate improvement

Other Repositioning Techniques

Depending on which canal is affected, your vestibular physiotherapist may use other maneuvers:

• Semont maneuver — An alternative for posterior canal BPPV
• Lempert (BBQ roll) maneuver — For horizontal (lateral) canal BPPV
• Deep head hanging maneuver — For anterior canal BPPV (rare)

Your vestibular physiotherapist will perform specific diagnostic tests to determine which canal is affected and select the most appropriate treatment.

Why Physiotherapy After BPPV Treatment Is Essential

While the repositioning maneuvers are highly effective at eliminating the vertigo episodes, many people continue to experience residual symptoms even after successful treatment. This is where comprehensive vestibular rehabilitation becomes crucial.

Addressing Residual Dizziness

Up to 50% of people successfully treated for BPPV report ongoing feelings of unsteadiness, lightheadedness, or “off-balance” sensations in the weeks following treatment⁴. This occurs because:

• The brain has adapted to the abnormal signals during the BPPV episode
• Compensation patterns may have developed that need to be retrained
• Confidence in movement may be reduced, leading to overly cautious behavior

Vestibular Rehabilitation Exercises

A physiotherapist specializing in vestibular rehabilitation can design a customized exercise program that may include:

• Gaze stabilization exercises — Training the eyes to stay focused during head movements
• Balance retraining — Progressive exercises to challenge and improve stability
• Habituation exercises — Repeated exposure to movements that provoke mild symptoms to reduce sensitivity
• Functional movement training — Practicing real-life activities in a safe, graded manner

Preventing Recurrence

BPPV has a recurrence rate of approximately 15% within the first year and up to 50% over five years⁵. Physiotherapy can help by:

• Teaching you to recognize early symptoms
• Providing home exercises to maintain vestibular function
• Educating you about risk factors and preventive strategies
• Addressing vitamin D levels and other modifiable factors

The Science Behind the Approach

Vestibular physiotherapy is grounded in our understanding of how the brain adapts to sensory information. The vestibular system works in concert with vision and proprioception (body position sense) to maintain balance and spatial orientation.

When one component of this system is disrupted—as in BPPV—the brain must recalibrate. This process, called vestibular compensation, can be facilitated and optimized through targeted rehabilitation exercises.

Research consistently supports the effectiveness of vestibular rehabilitation, with systematic reviews showing significant improvements in symptoms, balance, and quality of life for people with vestibular disorders⁶.

When to Seek Help

If you’re experiencing:

• Recurrent episodes of spinning dizziness
• Vertigo triggered by specific head positions
• Persistent balance problems or unsteadiness
• Anxiety about movement due to dizziness

Don’t wait to get help. BPPV is one of the most treatable causes of vertigo, and most people experience significant improvement with proper care.

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Experiencing dizziness or balance problems? Contact us to book an assessment with our vestibular physiotherapy team.

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References

1. Talaat HS, Abuhadied G, Talaat AS, Abdelaal MSS. Low bone mineral density and vitamin D deficiency in patients with benign positional paroxysmal vertigo. Eur Arch Otorhinolaryngol. 2015;272(9):2249-2253.

2. Jeong SH, Kim JS, Shin JW, et al. Decreased serum vitamin D in idiopathic benign paroxysmal positional vertigo. J Neurol. 2013;260(3):832-838.

3. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47.

4. Dispenza F, Mazzucco W, Mazzola S, et al. Residual dizziness after successful treatment of benign paroxysmal positional vertigo: A prospective study. Am J Otolaryngol. 2020;41(5):102621.

5. Brandt T, Huppert D, Hecht J, Karch C, Strupp M. Benign paroxysmal positioning vertigo: a long-term follow-up (6-17 years) of 125 patients. Acta Otolaryngol. 2006;126(2):160-163.

6. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015;1:CD005397.