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Benign Paroxysmal Positional Vertigo: It Will Make Your Head Spin!
pathology perspectives

By Ruth Werner

Originally published in Massage Bodywork magazine, July/August 2010. Copyright 2010. Associated Bodywork and Massage Professionals. All rights reserved.

The fear of losing one's balance--and subsequently falling and sustaining a serious injury--is a fact of life for many aged 50 and over. Some research suggests that up to one-third of all U.S. adults in this age group occasionally have bouts of dizziness or disequilibrium, and for those who do, the chance of falling is many times greater than that of the general population. One cause of these symptoms is benign paroxysmal positional vertigo (BPPV).

Our ability to stand erect and move through space is a tremendously intricate process. When we understand how complicated staying upright truly is, the question really becomes, why don't we fall over more often?

Anatomy Review: What Is Equilibrium?
The accurate sense of our position in space and our relationship to gravity is provided by the functional coordination of three sources of information: the eyes, which tell us where the horizon is (or at least horizontal lines, when we're unable to see the horizon); our proprioceptors, which tell us if our joints are bent, straight, or twisted (as well as whether our muscles are long, short, moving, still, or bearing weight); and the vestibular system in the inner ear. The vestibular system consists of specialized nerve endings from a cranial nerve (the vestibulocochlear nerve) that terminate in the vestibule--a hollow area in the inner ear where the semicircular canals converge. Vestibular nerve endings are suspended in fluid, and they sway like seaweed whenever the head moves or tilts in any direction. This movement of nerve endings within fluid is the basis for interpretation of our head's position.

If for some reason the signals we receive from these three sources don't match, our brain interprets this as being off-balance. Examples of mismatched information include the sensation we experience with amusement park rides that involve sitting still with a huge screen showing a projection of rapid movement--our eyes tell us we're moving, but our proprioceptors and vestibular nerves tell us we're not. The result: dizziness, nausea, and disequilibrium (and fun, if you like that sort of thing). Motion sickness is similar; this can be brought about simply by very rapid and sustained movement or by a disconnect between what the eye senses as the horizon and what the vestibular nerve conveys as upright versus horizontal.

Types of Balance Disorders
Because senior citizens are among the fastest growing demographic of Americans, and because many of them seek massage or bodywork to help them cope with their health challenges, it behooves massage therapists to be well-informed about some of the balance disorders these clients can experience. We will focus on one fairly common condition called BPPV. But first, let's look at some of the other threats to equilibrium that clients of any age may face.

Labyrinthitis
This is inflammation within the bony or membranous labyrinth of the inner ear. It is usually related to a self-limiting viral infection, but the pathogen is not always identified. This condition--which involves dizziness, hearing loss, and headache--tends to last a few days or weeks, and then gradually subsides.

Acute Vestibular Neuropathy
This is damage to the vestibular portion of cranial nerve VIII. If the cochlear branch is affected, hearing loss may develop, along with vertigo. Like labyrinthitis, this condition may be related to viral infection. It tends to be self-limiting and is usually resolved within a few days or weeks.

Meniere Disease
This idiopathic condition involves episodes of vertigo along with tinnitus (ringing in the ears), hearing loss, and a feeling of fullness in the middle ear. It is not well understood, but some experts believe it has to do with the accumulation of too much fluid within the bony labyrinth.

Head Injury
Blows to the head, violent sneezing, or whiplash-type accidents can cause inner ear fluid to leak into the middle ear in a condition called perilymph fistula. This can also occur with barotraumas, a type of injury frequently associated with scuba diving accidents.

These balance disorders are most common in mature adults, but they certainly aren't exclusive to that population. Other causes of disequilibrium include central nervous system problems like stroke, tumors, multiple sclerosis, or migraine headaches. Allergies and nasal congestion that block the eustachian tubes can interfere with fluid in the inner ear. Some psychological disorders (specifically anxiety and depression) can cause vertigo, as can medications to treat those conditions. Additional drugs, including alcohol, barbiturates, anti-hypertensives, diuretics, and cocaine can also cause balance loss.

BPPV: Etiology and Symptoms
The layout of the inner ear is complex. The vestibule, a hollow area at the center of the bony labyrinth, has several sub-portions. Tiny crystals of calcium carbonite called otoliths (literally "ear stones") are normally embedded in a gel-like substance within the vestibule. In BPPV, these otoliths fall out of position and into the semicircular canals. Their movement stimulates the vestibular nerve endings, creating an intense sensation of spinning--this is the definition of vertigo.

Direct causes of BPPV can be difficult to trace. It can develop after a head trauma, but the majority of cases are not connected to a specific triggering event. BPPV strongly correlates to age: most new diagnoses are in people aged 50 and over.

The most reliable triggers for bouts of BPPV involve changes of position of the head. Getting up, lying down, rolling over in bed, tilting the head to look up or down--any of these movements can elicit an attack of vertigo, which may be described as a feeling of spinning, or that the world is spinning around the affected person. Other symptoms commonly seen with BPPV include dizziness (this is distinct from vertigo, because while it may suggest that it is difficult to orient to the horizon, dizziness doesn't necessarily involve a spinning sensation), lightheadedness, nausea, and possible vomiting. BPPV has two markers that distinguish it from other balance disorders: it is not associated with headache pain, tinnitus (ringing of the ears), or a feeling of fullness in the ears; and it is associated with nystagmus--the phenomenon of having the eyes involuntarily oscillate during an episode.

Treatment Options
The great news about BPPV is that, compared to other causes of vertigo, it is relatively easy to treat. Because the symptoms are brought about by otoliths falling out of their correct location, carefully positioning the head in a sequence of angles in relationship to the horizon, and allowing enough time for the tiny stones to float back where they belong, is a surprisingly simple and extremely effective treatment modality. This intervention, called the Epley maneuver, takes just a few minutes, and many BPPV patients find that after just one or two treatments their episodes of vertigo are reduced or even entirely eliminated. Some patients find that they have to repeat the procedure regularly, but this is not a terrible hardship. Once the sequence is learned, many people can even do it for themselves.

Research indicates that the Epley maneuver is successful for managing BPPV up to 70 percent of the time.1 For those patients for whom it is not adequate, surgery may be conducted to block the area where the otoliths become displaced. This obviously carries more risk of complications (including a low risk of permanent hearing loss) than the Epley maneuver, but it has a very high success rate for eradicating any future episodes of vertigo.

Where Does Massage Fit?
Because balance disorders are so common among mature adults, any massage therapist who has clients in the 50 years and older range needs to be aware of some of the special challenges this population faces--and balance may not be at the top of their list of concerns.
BPPV is specifically linked to changes in the head's position in relationship to the horizon, so clients with this condition may have trouble lying down, getting up, or rolling over on the table. Similarly, any bending or twisting that has to happen while a client gets dressed may trigger an episode, so it is important to be close by and available in case of problems. Fortunately, most people will know what their triggers are and will have strategies to minimize the risk of having a vertigo attack.

A massage therapist who regularly works with clients who have BPPV may be interested to learn the Epley maneuver. As long as a client is officially diagnosed with BPPV and other complicating factors have been ruled out, this is well within our scope of practice and the risk for harm is extremely low. The best resource, if it is available, is to get instruction from the client's health care provider: their doctor, nurse, or physical therapist. But the Epley maneuver is so simple that it is easy to find written descriptions or video demonstrations online. A good one is available on YouTube, under the title "Epley for Dizziness": www.youtube.com/watch?v=QikUTAmeE0M. It is important to emphasize that working this way is only appropriate when a client has an official diagnosis and other possible disorders have been ruled out.

Skilled massage with the Epley maneuver can make a powerful impact for a client with BPPV. But massage may have even more to offer our older clients with balance issues. Trigger points in the anterior neck muscles can contribute to sensations of dizziness, and resolving these may offer relief that other interventions (often involving antinausea drugs and tranquilizers) may not. It is important to be clear that a client is not at risk for carotid atherosclerosis (a type of cardiovascular disease) before working deeply on the lateral neck, however. Clients who are older may also have limited sensation in their feet due to poor circulation, diabetes, or both. Research indicates that massage designed to stimulate local circulation and nerve supply may improve a client's ability to walk with a lower risk of falling--all of this is contingent on he or she being able to keep up with any homeostatic challenges that massage may present, of course.

Senior citizens are a growing population group in our society, and they are enthusiastic consumers of massage therapy. This group is obviously vulnerable to health challenges that the rest of the population doesn't have to deal with as often, and balance disorders are high on that list. A massage therapist who is comfortable and skilled in working with this population will find a rewarding specialty.

Ruth Werner is president of the Massage Therapy Foundation. She is a writer and NCBTMB-approved provider of continuing education. She wrote A Massage Therapist's Guide to Pathology (Lippincott Williams Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Her new book, Disease Handbook for Massage Therapists, is now available. Werner can be reached at www.ruthwerner.com or wernerworkshops@ruthwerner.com.

Note
1. M.J. Ruckenstein, "Therapeutic Efficacy of the Epley Canalith Repositioning Maneuver," Laryngoscope 111, no. 6 (June 2001): 940-5.




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