Timothy C. Hain, MD •Page last modified: May 17, 2021
|BPPV is caused by crystals dislodged from the utricle of the inner ear.|
Most of our patients find internet video's to help them through the home BPPV exercises. Here we have put a few links and comments. If you have a favorite, you are welcome to contact me and I may add it to the list (with comments of course). Some of these are pretty sad.
Well anyway, here are the ones I took a look at so far.
Vestibular today. This video that shows the R Epley maneuver. The positions look good, and I think it could be used as a right BPPV treatment demo. I liked the fact that the blog page used my educational material on BPPV (i.e. many pictures from this website). The pictures of an inner ear that accompanied the maneuver, were a little puzzling though -- and did not show that the posterior canal is vertical with the R ear down, horizontal with the left ear 45 deg down, and again vertical when the head is rolled another 90 degrees to the left. I think that this could be improved, perhaps with some up/down references in the background, or perhaps with the use of a computer model rather than photos of a model. Still, pretty good. Another video from the same PT (Danielle) is here. This is of the right side again. She does have some more material about the mechanism. All pretty good.
Bob and Brad. This page shows the L Epley maneuver. It is a little off in that the end of the maneuver has the nose looking totally down at the floor, rather than 45 degrees. It also leaves out the head-tuck at the end. Overall, has more room to improve. This video also shows the Dix-Hallpike, and has some discussion of other canals. I think this could be very confusing.
Ask Dr. Jo. This video had a very long annoying advertisement at the beginning about a "ground breaking toothbrush". Please. Dr. Jo is a physical therapist, not a medical doctor. This is pointed out with a disclaimer (I guess). I would prefer a video that just "got down to business", and didn't spend so much time talking. The first third of the video is occupied with talking. There are also errors. The head position is too far rotated -- should be 45 degrees, actually looks more like 90. Perhaps this is just an unthoughtful production. The head left position looks OK, but she recommends 2 minutes (!). Epley suggested 30 seconds. Practically it depends on how long one is dizzy. The head-down position is probably a bit off as well, as the head is not 45 deg down, but rather looks as if it is in the horizontal plane. At the end of the maneuver, there is no head tuck (as I prefer). There is then a suggestion of keeping upright for 48 hours (!) That's a long time Dr. Jo. So overall, this video is not my favorite either.
Boystown. This one is from Kristen Janky, Au.D. (i.e. not a PT or medical doctor, but an audiologist). This doesn't actually show a home Epley, but rather shows a practitioner type Epley on an exam table. The head positions also looks a bit wrong, similar to Dr. Jo. The head is turned 90 degrees here, rather than 45 degrees. This is suboptimal. On the nose down position, same error (i..e 90 degrees down). This might be a good maneuver for lateral canal BPPV however as it somewhat resembles a log-roll in head positions. Again, no head tuck. Overall, this video is not my favorite at all because of the issues with the head positions. It doesn't show the home maneuver either.
The Semont Maneuver is as good as the Epley because it incorporates the same head positions. The home Semont was found by Radke (1999) to be a little less effective than the home Epley. We think it is a "fall back" home maneuver.
This maneuver is shown accurately and is very reasonable. We think the home Semont should be done only if the home Epley fails, as Radke (1999) showed that the home Epley was more effective. The left is illustrated here. We are a little surprised to see the recommendations for 10-15 minutes head upright afterwards, but no harm done I suppose. We think people should not lie flat for the remainder of the day and also sleep propped up for a night or two. However, if people are doing this every day for a week, the post-maneuver precautions may not matter.
This video has a lot of annoying advertisements, and also takes quite a while to get to the point. However, the discussion is accurate, it just takes more than half of the video. This is not a home treatment, it is clearly for practitioners. This video uses pillows -- we do not think this is helpful. The head position with nose down position looks a little wrong -- the nose should be 45 degrees down. Overall, we prefer the U. Mich video.
Foster maneuver. (this is the head forward maneuver). Made by Dr. Foster
The first half of this video is explanation. Production quality is good. This video is a bit long, and has a lot of material in it about BPPV in general, rather than directly illustrating the maneuver. Dr. Foster (2012) wrote about her own maneuver and said it was not quite as effective as the home Epley.
Lateral canal BPPV can be extremely severe, and it is also pretty easy to distinguish from PC BPPV, so these videos are relevant. We just consider one here, which is OK. The lateral canal is a little tilted up from horizontal, and thus in theory one would want head positions that take this into account (i.e. be a little head tucked) to make the lateral canal vertical. This is not done on the following video (for example, see 2:19). So room for improvement.
This video of the log-roll maneuver is reasonable, although we have a few comments. The first video is for the L side. We think the nose down position (end of maneuver just before getting up) is a little unfortunate, as the head is held somewhat up (at 2:19 on the timeline) rather than down with the head cradled in one's hands. This video also shows the R side treatment (which is of course just the mirror image).
The discussion as to which ear is the bad one implies that people can figure this out and "gauge how dizzy you get". This is not so easy, and this of course also depends on the type of lateral canal BPPV. We are doubtful that a patient will be able to figure out the bad ear, as it is pretty difficult for clinicians with better equipment. We think patients ideally should see an expert, and failing this, just use a trial/error process (on different days).
We are very dubious that patients should be doing the Gufoni treatment for BPPV, as it is difficult even for providers who have better information (i.e. Frenzel goggles). For this reason, we do not review the home Gufoni maneuvers.
The maneuvers for the anterior canal are obscure. Basically they involve the head being upside down, in an attempt to get the anterior canal debris to move. As AC BPPV is not very common, these are not so important.
|Treatment for AC BPPV as proposed by Kim and associates (2005). In position 'b', the head is turned 45 degrees towards the symptomatic side. Note that the illustrations of the canals from the Kim article (shown above) are anatomically impossible artists renditions.||Deep head hanging treatment for AC BPPV as proposed by Yacovino, Hain and Gualtieri. (2009). This treatment differs from that of Kim (above) in that the head is not turned to either side, and it is positioned so that it is further back with respect to horizontal in position 2.|
These first two are of the Yacovino maneuver (see above)
Deep Head Hanging. This video (done with an animation, probably Poser) has the correct positioning for the Yacovino maneuver for AC BPPV (2009). The author of this page was a coauthor of that paper. This video is reasonable but could be better. There is no consideration of turning the head to either side (i.e. similar to the Kim maneuver). The animation seems to show unrealistic geometry for the anterior canal as well. We suggest a redo.
Educated PT -- Deep head hanging The production quality is not the best. The first position (30 degrees back), followed by 30 degrees of head flexion, seems to us to be unlikely to work. We suggest passing on this one.
Anterior canal BPPV -- This is another Yacovino maneuver. It is similoar to the first one.
We were not able to find a video of the Kim maneuve for AC BPPVr. Logically the maneuver should not work as well as the "deep", meaning 60 degree, Yacovino. However, we think the head turning is clever.
|Illustration of Rahko's maneuver, from Korres (2010).|
Rahko maneuver. There is a video found by search for the Rahko maneuver (thankfully without advertisements), that doesn't seem to follow the illustration of the maneuver by Korres. We would not suggest this video. We think the illustration above is more informative. This maneuver is better suited to people who cannot extend their neck 60 degrees (which might be a lot of people), than the Yacovino maneuver which requires quite a bit of flexibility.