Over the past 6 years CardioFlex Therapy has successfully treated hundreds of vertigo patients, and assisted them in eliminating their dizziness. I want to share some concepts of how to use Vestibular Rehabilitation to get maximum results for Benign Paroxysmal Positional Vertigo (BPPV) patients.

Diagnosis

The first step in getting rid of dizziness begins with a solid diagnosis. Does the patient have a peripheral or a central problem? What causes the patient to get dizzy? Is there any spinning vertigo with the dizzy episodes? Patients that have Meniere’s Disease or other chronic conditions will get recurring bouts of dizziness, so helping them resolve each episode quickly will be the best case scenario for those individuals.

Central Vertigo involves brain and spinal cord lesions such as tumors, cysts, surgeries, scar tissue, and degeneration. Neuromuscular disorders such as Multiple Sclerosis, Ataxia, Stroke, & Parkinson’s Disease can affect the cerebellum in the brain, causing gait and balance disturbances as well as severe vertigo. Peripheral Vertigo is typically considered to be caused by anything not in the central nervous system (brain and spinal cord). Much of the time, Peripheral Vertigo is synonymous with Positional Vertigo (BPPV).

To truly diagnose the vertigo as peripheral, the patient must have a brain MRI to rule out central involvement. A Hallpike Dix test and a Supine Roll Test are performed to see if the patient has Positional Vertigo on the left side, the right side, both sides, or not at all. Positional Vertigo (BPPV) is caused by displaced otoconia, commonly called crystals, which tend to get stuck in the 3 semicircular canals. The Hallpike Dix Test will be positive if crystals are stuck in either the Anterior or Posterior canals. The Supine Roll Test will be positive if crystals are stuck in the Horizontal canals.

Eye tests need to be conducted with and without head movement to see if there is a visual sensory-in component. In other words, if a patient gets dizzy from visual tests with or without head movement, then there is probably a visual sensory-in pathway which can trigger the symptoms at any time, usually seen with severe vertigo. If the patient gets any nystagmus (spinning vertigo), then they have a sensory-out component through their eyes, and are more likely to have a sensory-in component as well.

Treatment

At CardioFlex, we believe in a concept that we call "Repetitive Maneuvers." We believe that several maneuvers should be performed in each treatment session in order to clear the crystals out of the semicircular canals, and become free flowing like they were before getting stuck. There are several maneuvers that we like to use in our sessions to clear the crystals, such as the Brandt-Daroff Maneuver, the Semont Maneuver, Epley’s Maneuver, and the Barbeque Roll Maneuver.

Vestibular Rehabilitation

The Brandt-Daroff Maneuver is the best maneuver to give to patients for a Home Exercise Program (HEP), because it’s the simplest maneuver to execute. In our clinic, we will have the patient do this maneuver first to get the crystals flowing, and get their vestibular system ready to handle more intense stimuli. After this maneuver, we will do eye exercises in sitting with the patient, if they have any sensory-in problems. If they don’t have any sensory-in dizziness, then we will proceed to static and dynamic balance exercises, with and without head movements. The head movements are either very small rapid movements, or slow full range movements, which are meant to disturb balance and aggravate the dizziness symptoms. After these balance exercises are done, we may decide to do some functional activities with head movements, such as squats, lunges, and different directional walking exercises. The goal of each therapy session is to aggravate the dizziness and clear the displaced crystals.

Which exercises we choose for the patient is based on a progressive loading pattern, starting off very easy then progressing to very difficult exercises by the end of therapy. At the end of each treatment session, we will do 1 power maneuver, such as the Semont Maneuver, Epley’s Maneuver, or the Barbeque Roll. Once they can handle a power maneuver without any adverse dizziness symptoms, then we will change the order of the maneuvers to enable as many as 4 maneuvers per session. The ideal order becomes: Brandt-Daroff Maneuver, Semont Maneuver, balance exercises, functional exercises, and lastly the Epley’s Maneuver.

The Brandt-Daroff, Semont, and Epley’s Maneuvers clear crystals in the Anterior and the Posterior semicircular canals, but not in the Horizontal (Lateral) canal. The Barbeque Roll Maneuver clears crystals in the Horizontal canal, so it’s really not needed unless the other maneuvers are not able to completely get rid of the vertigo, or if the patient tested positive for the Supine Roll Test (Horizontal BPPV test). When the Barbeque Roll test is incorporated, it should either be the last maneuver, or the 2nd to last maneuver performed, to get maximum results. If the Barbeque Roll test is either too violent for the patient to handle (gets sick, nystagmus, etc.) or the patient cannot physically do it (rolling over), then another Horizontal Maneuver can be used such as the Log Roll Maneuver or the Gufoni Maneuver.

At CardioFlex, we have used our "Repetitive Maneuver" method on hundreds of vertigo patients with tremendous success. Due to the volume of patients who have had rapid results from our methods, we are very confident in our expertise treating patients with vertigo, dizziness, and balance disorders.