Benign paroxysmal positional vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness and is defined as a disorder that causes vertigo, dizziness, and other symptoms due to debris that has moved from a part of the inner ear to the semi-circular canals. This debris, called otoconia, (or ‘ear rocks’) is made up of small crystals of calcium carbonate. With head movement, the displaced otoconia shift, rolling in the semi-circular canals and sending false signals to the brain that you are still in motion even after you’ve stopped moving.

Symptoms of BPPV are almost always precipitated by a change in head position, which is one of the tell-tale signs of diagnosis. Getting out of bed and rolling over in bed are two common "problem" motions. Some people feel dizzy and unsteady when they tip their heads back to look up. An intermittent pattern of these symptoms is usual – they come and go.

About 20% of all dizziness is due to BPPV and it is the most common cause of dizziness in people under age 50, commonly with a history of past head injury. About 50% of dizziness in older people is due to BPPV. In half of all cases, BPPV is idiopathic, which means that it occurs for no known reason. However, ‘idiopathic’ just means that no one has been able to figure it out, because we all know, there IS a cause. BPPV is also associated with a characteristic nystagmus (jumping of the eyes), and tests such as the Dix-Hallpike test and electronystagmography (ENG) diagnose the case. Without the use of special diagnostic goggles, it is difficult to see the nystagmus.

Epley’s maneuver and the Semont-liberatory maneuver are very effective in treating BPPV and can be performed in our office in about 15 minutes. The goal of these maneuvers is to move the detached otoconia out of one of the semicircular canals. Treatment may also include individualized Brain-Based Therapy exercises designed to help “retrain the brain” as well as testing to find the ‘cause’ of the otoconial detachment. 

Meniere's Disease

Meniere's disease is a vestibular (inner ear) disorder that produces a recurring vertigo and other symptoms as a result of abnormally large amounts of a fluid called endolymph collecting in the inner ear. 

The prevalence of Meniere's disease is difficult to assess and often mis-diagnosed. The exact cause of Meniere's disease is misunderstood as well. Theories include circulation problems, viral infection, allergies, autoimmune disease, and the possibility of a genetic connection. Experts also aren't sure what generates the symptoms of an acute attack. Some people with Meniere's disease find that certain triggers can set off attacks, including stress, overwork, fatigue, emotional distress, additional illnesses, pressure changes, certain foods, and too much salt in the diet.

Attacks can last from 20 minutes to 24 hours. They can occur many times per week; or they can be separated by weeks, months, and even years. The unpredictable nature of this disease makes it difficult to tell how it will affect a person's future. Symptoms can disappear one day and never return, or they might become so severe that they are disabling.

During an attack of early-stage Meniere's disease, the main symptoms are spontaneous, violent vertigo, fluctuating hearing loss, ear fullness, and/or tinnitus. Following the attack, a period of extreme fatigue or exhaustion often occurs, prompting the need for hours of sleep. The periods between attacks are symptom-free for some people and symptomatic for others.

Late-stage Meniere's disease refers to a set of symptoms rather than a point in time. Hearing loss is more significant and is less likely to fluctuate. Tinnitus and/or aural fullness may be stronger and more constant. Attacks of vertigo may be replaced by more constant struggles with vision and balance, including difficulty walking in the dark and occasional sudden loss of balance.

As with any disorder, we need to dig back to possible causes. I have found that vascular problems are common with Meniere’s patients. Since the ear (like the heart) is fed by terminal vessels (most of our body has a secondary blood supply in the event of vascular occlusion, much of the ear and heart lack this), any obstruction of the blood supply will cause issues. One theory I’ve developed, a contraction of the intimal lining of the arterial walls (intermittently) will cause an ischemic event (lack of oxygen for a short time – almost like an ‘ear stroke’) that precludes a Meniere’s attack. There is a possible nutritional reason this may occur. The lumen of our blood vessels are ‘held open’ by the muscular tone of the smooth muscles that line them. These are the small, delicate muscles that our sympathetic nervous system innervates and effects changes to when we are in a ‘fight-or-flight’ situation and need to shunt blood rapidly to parts of the body aiding our battle with the foe.

From a nutritional point of view, muscle contraction and dilation of the arteries requires mineral stores and specific vitamins. Deficiencies and problems of absorption may be at cause in Meniere’s cases. The ultimate goal of this treatment is to find and correct the cause. A full and extensive ‘work-up’ is in order, but there IS a reason for this and any other problem.

Aging, Balance, and Dizziness 

Balance issues are commonly confused with dizziness. One of the leading health concerns for people over 60 is falling. Balance in walking and standing is dependent on many factors, like peripheral neuralgia, vision issues, and coordination and sensory problems. The most common problem for our loss of stability as we age is Cerebellar degeneration. The Cerebellum is the part of the brain near its base that coordinates all motor function and ‘fine-tunes’ our thoughts and actions. The elderly have a higher risk of contracting many different kinds of diseases that can interfere with balance, including cataracts, glaucoma, diabetic retinopathy, and macular degeneration, which all affect vision; peripheral neuropathy, which affects position sense in the feet and legs; and vestibular-system degeneration. 

The presence of dizziness in the elderly can be a result of problems with the inner ear, the brain, the cerebellum, the vision systems, as well as from neuropathy, and psychological causes. Cerebellar disorders, however, are thought to be the most common cause of dizziness as we age. 

Brain Based Therapy (BBT)

What is BBT?

Brain-Based exercise programs are designed to promote central nervous system re-connections for inner ear deficits. BBT can help with a variety of vestibular problems, including benign paroxysmal positional vertigo (BPPV), Cerebellar deficits, vision and Frontal Lobe problems Ménière’s disease, labyrinthitis, and vestibular neuritis.

Who benefits from BBT treatment?

When the vestibular organs are interfered by disease, inflammation or injury, the brain receives inaccurate information about equilibrium and motion, often resulting in dizziness, vertigo, balance problems, and other symptoms. Many people with healthy brain activity are able to recover from these symptoms on their own after a few weeks of normal activity because the brain has adapted with a process called vestibular compensation.

However, if the brain compensation process is not successful, a person's ability to maintain posture and balance may be compromised. A person may develop new patterns of head and body movement to avoid dizziness and nausea, adopt a pelvic sway or compensatory subluxation pattern in an attempt to balance, exhibit a head tilt and/or rotation to ‘set their world straight’, that leads secondary headaches, muscle spasms, and fatigue. 

The astute Functional Neurologist will pick up on these subtle signs which may be the only early indications of a degenerative process that may lead to a debilitating future for the patient.

Of course, BBT alone, without removing the initial cause, will do nothing to correct the problem. Example: if the patient suffers from dizziness due to an inflammatory autoimmune response, BBT may aid in rehabilitation only after the causative agent (in this case the antigen in the autoimmune attack and the subsequent inflammation) is removed.