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30 Seconds Of Therapy: BPPV Step-by-Step: Start with Dix–Hallpike, Treat with Epley.

Nov 6

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A physical therapist performing the Side-Lying Test, an alternative to the Dix–Hallpike maneuver, to diagnose Benign Paroxysmal Positional Vertigo (BPPV) in a clinical physical therapy setting.

When a patient says, “The room spins when I roll over or sit up,” your next move could change everything. Vertigo — especially Benign Paroxysmal Positional Vertigo (BPPV) — is one of the most common yet most treatable causes of dizziness.  


START


  1. Precise screening — and do it right. 

    1. Use the Dix–Hallpike test for posterior canal BPPV and the Roll Test (Pagnini–McClure) for horizontal canal involvement.  

      1. Seat the patient, turn their head 45° toward the test side.

      2. Quickly guide them to a supine position with their head 20–30° below the table edge.

      3. Watch for upbeating, torsional nystagmus — your classic BPPV indicator.

      4.  If symptoms don’t appear, repeat or try the side lying variation. Sometimes subtle nystagmus hides on the first attempt.

  2. Treating on the spot  

    1. Once confirmed, move immediately to the Modified Epley Maneuver:

      1. Begin in the positive Dix–Hallpike position.

      2. Wait until vertigo subsides.

      3. Rotate the head 90° to the opposite side.

      4. Roll the patient onto their shoulder, then assist them to sit upright.

    2. In many cases, one or two maneuvers are all it takes to restore balance — a simple, powerful example of evidence-based manual care

  3. Empowering through Education

    1. Teach patients how to recognize their symptoms. BPPV vertigo typically lasts less than one minute and is triggered by head movement, not constant at rest. Encourage gentle head motion throughout the day — staying still can actually slow their recovery.


STOP


  1. Dizziness equals concussion — test, don’t guess. 

    1. It’s easy to attribute post-injury dizziness to central causes, but when symptoms are brief, positional, and fatigable, the vestibular system is usually to blame.

    2.  Instead of assuming, test early using positional maneuvers. Catching BPPV early prevents unnecessary imaging and medication reliance.

  2. Skipping the retest — verify your findings

    1. If your first Dix–Hallpike or Roll Test is negative, repeat it. The otoconia might not shift enough during the first trial to trigger symptoms.

    2. Allow a short rest, then test again. This small step can make the difference between a missed diagnosis and a confident, corrective treatment.

  3.  Imposing unnecessary post-treatment restrictions — update your practice

    1. Advice like “sleep upright” or “avoid lying flat for 48 hours” 

    2. Instead, encourage normal head movement, reassure your patient about possible mild imbalance for a day or two, and schedule a follow-up to confirm resolution.


WHY


  1. Because movement heals. 

    1. The vestibular system thrives on motion. Encouraging gradual head and eye movement after repositioning helps recalibrate the system faster and improves long-term stability.

  2. Your confidence restores theirs  

    1. A calm, skilled clinician transforms a frightening experience into a moment of relief. Your steady hands — and assurance — are often the first step toward a patient’s recovery.




References: MedBridge BPPV and Vestibular Advances in Concussion Susan Whitney, DPT, PhD, NCS, ATC, FAPTA 1. Akin FW, Murnane OD, Hall CD, Riska KM. Vestibular consequences of mild traumatic brain injury and blast exposure: a review. Brain injury. 2017;31(9):1188-94. 2. Alkathiry AA, Kontos AP, Furman JM, Whitney SL, Anson ER, Sparto PJ. VestibuloOcular Reflex Function in Adolescents With Sport-Related Concussion: Preliminary Results. Sports health. 2019;11(6):479-85. 3. Alshehri MM, Sparto PJ, Furman JM, Fedor S, Mucha A, Henry LC, et al. The usefulness of the video head impulse test in children and adults post-concussion. Journal of vestibular research : equilibrium & orientation. 2016;26(5-6):439-46. 4. Balaban C, Hoffer ME, Szczupak M, Snapp H, Crawford J, Murphy S, et al. Oculomotor, Vestibular, and Reaction Time Tests in Mild Traumatic Brain Injury. PloS one. 2016;11(9):e0162168. 5. Balaban CD, Kiderman A, Szczupak M, Ashmore RC, Hoffer ME. Patterns of Pupillary Activity During Binocular Disparity Resolution. Frontiers in neurology. 2018;9:990. 6. Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic review of the balance error scoring system. Sports health. 2011;3(3):287-95. 7. Brodsky JR, Lipson S, Wilber J, Zhou G. Benign Paroxysmal Positional Vertigo (BPPV) in Children and Adolescents: Clinical Features and Response to Therapy in 110 Pediatric Patients. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2018;39(3):344-50. 8. Brodsky JR, Shoshany TN, Lipson S, Zhou G. Peripheral Vestibular Disorders in Children and Adolescents with Concussion. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2018;159(2):365-70. 9. Broglio SP, Harezlak J, Katz B, Zhao S, McAllister T, McCrea M. Acute Sport Concussion Assessment Optimization: A Prospective Assessment from the CARE Consortium. Sports medicine (Auckland, NZ). 2019;49(12):1977-87. 10. Brown LA, Hall EE, Ketcham CJ, Patel K, Buckley TA, Howell DR, et al. Turn Characteristics During Gait Differ With and Without a Cognitive Demand Among Collegiate Athletes. Journal of sport rehabilitation. 2019:1-20. 11. Buttner F, Howell DR, Ardern CL, Doherty C, Blake C, Ryan J, et al. Concussed athletes walk slower than non-concussed athletes during cognitive-motor dual-task assessments but not during single-task assessments 2 months after sports concussion: a systematic review and meta-analysis using individual participant data. British journal of sports medicine. 2019. 12. Carrick FR, Hankir A, Zaman R, Wright CHG. Metrological Performance of Instruments used in Clinical Evaluation of Balance. Psychiatria Danubina. 2019;31(Suppl 3):324-30. 13. Diaz DS. Management of athletes with postconcussion syndrome. Seminars in speech and language. 2014;35(3):204-10.


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