Benign paroxysmal positional vertigo (BPPV) and osteopathy

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo in adults, affecting approximately 2.4% of the population during their lifetime. It is benign but can be extremely debilitating, affecting quality of life on a daily basis.

In this article, we will explore VPPB in depth: from the underlying anatomy to causes, symptoms, diagnosis, and multidisciplinary treatments. Whether you are a patient, a loved one, or a healthcare professional, this article will help you better understand and manage this condition.

To understand BPPV, it is essential to delve into the anatomy of the inner ear, where the vestibular system responsible for balance is located. The inner ear, also known as the labyrinth, consists of two main parts: the cochlea for hearing and the vestibule for balance. The latter includes the semicircular canals—three tubes shaped like semicircles oriented in the horizontal, anterior, and posterior planes—filled with a fluid called endolymph.

Within the vestibule are the otolith organs: the utricle and saccule, which contain calcium carbonate crystals called otoconia or otoliths. These crystals detect linear acceleration and gravity. In the semicircular canals, hair cells sensitive to rotational movements of the head transmit signals to the brain via the vestibular nerve.

When everything is functioning normally, this system maintains balance and coordinates eye movements (vestibulo-ocular reflex). But in BPPV, a malfunction occurs: the otoconia detach from the utricle and migrate into a semicircular canal, often the posterior canal (in 85-95% of cases). This abnormal displacement causes erroneous signals when the head position changes, leading to intense dizziness.

Individual anatomical factors, such as the shape of the canals or the density of the otoconia, can influence susceptibility to BPPV. In older people, natural degeneration of the vestibular structures increases the risk, explaining why this condition more commonly affects those over the age of 50.

BPPV is mainly caused by the displacement of otoliths or otoconia in the semicircular canals, a phenomenon known as canalolithiasis. In most cases (50-70%), the cause is idiopathic, meaning there is no apparent reason. However, several triggering factors have been identified:

From an osteopathic perspective, cervical dysfunctions, such as tension in the C1-C2 vertebrae, can indirectly contribute by altering proprioception and nerve signals to the vestibule. In vestibular physiotherapy, it has been observed that musculoskeletal disorders aggravate symptoms, highlighting the importance of a holistic approach.

The symptoms of BPPV are characteristic and aid in early diagnosis. The vertigo is paroxysmal (sudden and brief), positional (triggered by changes in position), and benign (without serious long-term consequences).

Unlike other types of vertigo (such as vestibular neuritis), BPPV does not affect hearing and does not cause muscle weakness. However, in elderly patients, it increases the risk of falls, with potentially serious consequences such as fractures.

If symptoms persist or are accompanied by severe headaches, hearing or neurological problems, urgent medical attention is required to rule out more serious causes such as a stroke.

The diagnosis of BPPD is based on the patient's medical history and positional tests. The French National Authority for Health (HAS) recommends a systematic evaluation to identify the canal involved.

From a physical therapy perspective, I include an assessment of balance (such as the Romberg test) and posture to detect muscular compensations. In osteopathy, I palpate the cervical spine to identify restrictions that could mimic or aggravate symptoms.

An accurate diagnosis is crucial, as it guides treatment: 90% of BPPV involve the posterior canal, but horizontal (10%) or anterior (rare) forms require tailored approaches.

In ENT, the first-line treatment is non-medicinal and aims to reposition the otoconia. Liberatory maneuvers are effective in 70-90% of cases after one or two sessions.

Medications (such as anti-vertigo drugs) are reserved for acute symptoms, but do not treat the cause. In the event of recurrence (30% of cases), a referral for vestibular physiotherapy is systematic.

Vestibular rehabilitation is one of the cornerstones of BPPV treatment, with success rates of 85-95%. It goes beyond maneuvers and includes exercises to accustom the brain to abnormal signals (habituation) and improve compensation.

Sessions last 45-60 minutes, with 4-6 typical visits. For elderly patients or those with comorbidities, progressive exercises are incorporated to prevent nausea. Studies show that vestibular physiotherapy reduces recurrence by 50%.

My expertise in osteopathy and chiropractic allows me to approach BPPV from a holistic perspective, treating the somatic dysfunctions that exacerbate symptoms. Although not first-line treatments, these approaches perfectly complement ENT and physical therapy.

These methods are particularly effective for mixed vertigo (vestibular + cervical), with benefits in terms of mobility and symptom reduction. They complement vestibular rehabilitation by addressing biomechanical aspects, promoting overall recovery. Exercises are often given to patients to complement treatment and limit the risk of recurrence (such as tilting the neck or moving the ear toward the shoulder).

Preventing recurrence is key.

• Avoid sudden head movements in the short term;
• Sleep with your head elevated (two pillows) during episodes of dizziness.
• Practice daily balance exercises such as yoga or tai chi.
• Maintain adequate hydration and a calcium-rich diet to preserve the otoliths.
• For seniors, regular ENT and osteopathic checkups are recommended.

If you experience an episode, remain still for 1-2 minutes after the dizziness subsides, then move slowly.

One of the most common misconceptions among patients suffering from BPPV is often this: "Since I've been experiencing vertigo, I'm very careful not to move my head too quickly, not to bend over, not to look up..."

Exactly the opposite should be done (gradually and intelligently).

The vestibular system, like all sensory systems in the human body, functions according to the principle of adaptation and tolerance to stimuli. When we systematically avoid all movements that cause dizziness, we create a very classic vicious circle:

Frequent outcome after several months of extreme avoidance: BPPB that was initially very easy to treat becomes chronic and stubborn, with the onset of persistent postural imbalance symptoms and extreme sensitivity to even the slightest head movements.

The longer you go without ever putting your head in a position of significant relative imbalance, the greater the risk that even the slightest movement of the neck will become pathological.

This is exactly the opposite of the principle of vestibular rehabilitation: the system is deliberately and gradually exposed to various positional and angular stimuli in order to:

Once the acute phase has passed and, ideally, after performing one or more maneuvers to relieve the condition (Epley, Semont, Gufoni, etc.), the fear of movement is often more debilitating than the BPPV itself.

In summary:

So, as soon as the dizziness becomes bearable, don't hesitate to gradually retrain your head and balance. This is one of the best-kept (and most counterintuitive) secrets to a good long-term recovery from BPPV.

Although benign, BPPV requires multidisciplinary attention for rapid resolution. Combining ENT expertise, vestibular rehabilitation, and osteopathic approaches yields optimal results. If you suspect BPPV, act quickly: a consultation can change your life.