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Vertigo: A dizzying problem with a potentially simple solution

February 3, 2015

(Dallas, TX) In a moment, Teresa Johnson’s world spun out of control.

The 47-year-old Arlington resident was finishing up a workout at home last summer when she hit the floor for crunches. Suddenly, the room started to spin, so violently that she immediately became sick to her stomach.

“There was no warning at all,” she says. “I was terrified.”

For the next two weeks, as she waited for an appointment with an ear, nose and throat specialist, Johnson was constantly nauseated. She couldn’t drive. She couldn’t exercise. She managed to stave off the worst of the vertigo by keeping her head in a particular position, but still felt quite dizzy.

After two appointments and a series of tests, including a CT scan of her head, the physician prescribed physical therapy, much to her surprise.

“I thought that was crazy,” she says. “I thought I’d get a pill.”

Johnson saw Cindy Nolan, a physical therapist at Methodist Mansfield Medical Center, who guided her head through a series of four painless positions.

That did it. In just a few minutes, the vertigo Johnson had endured for six weeks was gone.

Vertigo — the sensation that the world around you is spinning, even though you are perfectly still — can stem from a variety of causes, ranging from an inner ear infection to head injury or stroke.

In Johnson’s case, the diagnosis was benign paroxysmal positional vertigo, or BPPV. That’s a common form of vertigo that affects millions of people, about 9 out of every 100 older adults. While it’s not life-threatening, it can be life-disrupting and frightening.

“Patients who have this are often scared because they don’t know what they’re dealing with,” says Jeremy McSpadden, a doctor of physical therapy at Baylor Institute for Rehabilitation. “They can’t feel stable. They can’t drive.”

The characteristic symptom of BPPV is vertigo that occurs in brief bouts — usually a minute or less — when the head is in a specific position, according to Dr. Chung-En Huang, an otolaryngologist at Methodist Charlton Medical Center.

“Usually the patient will say something like, ‘I lift up my head to pick something up from a shelf, and the room starts spinning,’ or ‘When I lie down, I have this spinning sensation,’” he says. If the vertigo is constant, it’s usually not BPPV.

With BPPV, tiny particles (called otoconia, or “ear rocks”) break off the lining of the walls of a canal in the inner ear, setting off spinning-motion sensors inside the ear and wreaking havoc on the patient’s balance.

Physical therapists or physicians can treat the problem with moves such as the Epley maneuver, which is what Johnson received. The Epley and similar particle-positioning maneuvers can fix the problem by shifting the head into positions that cause the particles to roll back into place. (Think of a ball in a puzzle maze, where you roll it around until it drops through the hole.)

In patients correctly diagnosed as having BPPV, these maneuvers work about 85 percent of the time, according to the American Physical Therapy Association.

“For patients with true BPPV, it’s generally a very easy fix,” McSpadden said. “Most patients need only one treatment and a checkup a week later.”

As to why the particles dislodge in the first place, that can be triggered by a blow to the head, but in most cases, Huang says, it’s idiopathic (which is a doctor word for “we have no idea why”).

One study indicated that women 50 and older are more susceptible to BPPV; researchers theorized that hormonal changes or bone loss might trigger the problem.

Nolan, who specializes in vestibular (inner ear) rehabilitation, notes that it’s especially important for older patients to get a good diagnosis and treatment, because vertigo and related balance problems can increase the risk of falls.

How it works

The Epley was invented around 1980 by Portland, Ore., physician John Epley, who initially faced skepticism and even derision from his colleagues.

Eventually his technique was confirmed in the New England Journal of Medicine as the standard treatment for BPPV, and by 2000 one small study decried data that showed that, on average, patients spent more than $2,000 in tests and failed treatments before being successfully treated with the Epley maneuver or a similar procedure.

The Epley is the most common treatment, but physical therapists employ other maneuvers, depending on exactly where the rogue particles have lodged. Dr. Carol Foster, director of the Balance Laboratory at the University of Colorado Hospital in Aurora, devised a series of movements, a sort of half-somersault, after a bout of vertigo inspired her to experiment. She created a video of what’s now called the Foster maneuver, and it has gone viral on the Web.

“I have seen patients admitted with horrible vomiting, just because they have particles lodged in the wrong canal,” Foster says in an online statement. “We do a $5,000 work-up on them only to figure out that this could be relieved in a second by a simple maneuver.”

Both Nolan and McSpadden say Foster’s move can be effective but caution that it’s important to see a medical professional to eliminate other, more serious causes for vertigo. In order for the Foster maneuver to be effective, patients must determine which ear has the problem. Nolan adds that the Foster maneuver might be risky for elderly patients or those with neck problems.

Nolan and McSpadden also both say they often see patients who’ve been to several doctors and endured vertigo symptoms for weeks or months before getting relief in a matter of minutes. However, the Epley and similar maneuvers don’t work for everyone.

Nolan says it’s important to get a solid diagnosis of BPPV.

“That’s why vestibular rehabilitation is a niche. You have to determine where the loose crystals are lodged, and once you’ve done that, you’ve usually fixed the problem.”

In Johnson’s case, the test that pinpointed her BPPV diagnosis involved wearing a set of goggles that tracked her eye movements, depending on the position of her head.

Omniax machine

The inventor of the Epley maneuver eventually saw the procedure’s limitations. Before retiring five years ago, Epley developed a machine called the Omniax. It looks like a giant human gyroscope, with the patient strapped inside. Goggles track the patient’s eye movements — the most accurate indicator of where the particles are lodged — as the patient is moved into a series of different positions. The Omniax then maneuvers the patient accordingly, sometimes into upside-down positions that would be virtually impossible on an examining table.

Cathy Epley, the inventor’s daughter, is marketing the Omniax; she says the machine offers the best tool for diagnosing BPPV (as well as some other types of vertigo) and for fixing it permanently. BPPV does tend to recur; about 50 percent of patients will experience another bout within three years. The device is not yet available in the Dallas area.

As for Johnson, she’s doing fine now. She marvels that the fix for the vertigo that was so disabling was just a matter of getting her head in the right place.

“I went in as a skeptic,” she says. “I was amazed.”

When to call 911

In most cases, vertigo is uncomfortable but not life-threatening. However, if vertigo is accompanied by any of these symptoms, seek immediate medical attention:

Blurred or double vision

Difficulty speaking

A change in alertness

Arm or leg weakness

Loss of motor control or inability to walk

Facial numbness or tingling

Drooping of the face or eyelids

SOURCES: American Physical Therapy Association, Jeremy McSpadden

(Source: dallasnews.com)


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