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ACRO E-mail Archive Thread: Wobblies


Thread: Wobblies

Message: Wobblies

Follow-Up To: ACRO Email list (for List Members only)

From: Tim Bastian <timothy607 at>

Date: Sun, 17 Nov 1996 05:55:55 UTC


  Just got this in my E-Mail and thought it might clear some things up. Please
read it. I think you'll find that it explains the Wobblies and what can be
done about them. a fully illustrated guide can be obtained directly from the
Vestibular Disorders Association <veda at> by sending them and
E-Mail with your name and mailing address.

 See ya,

     Tim Bastian

>From: Vestibular Disorders Association <veda at>
>Date: Mon, 11 Nov 1996 16:27:46 -0800 (PST)
>To: timothy607 at
>Subject: BPPV
>By Timothy C. Hain, MD
>Chicago, Illinois
>Benign Paroxysmal Positional Vertigo
>(BPPV) causes dizziness due to debris
>which has collected within a part of the
>inner ear. (See picture.) You can think of
>this debris as "ear rocks." Chemically, ear
>rocks are small crystals of calcium
>carbonate. They are derived from
>structures in the ear called "otoliths" that
>have been damaged by head injury,
>infection, or other disorder of the inner
>ear, or degenerated because of advanced
>The symptoms of BPPV include dizziness
>or vertigo, lightheadedness, imbalance,
>and nausea. Activities which bring on symptoms will vary in each person,
but symptoms
>are almost always precipitated by a position change of the head with
respect to gravity.
>Getting out of bed or rolling over in bed are common "problem" motions. Because
>people with BPPV often feel dizzy and unsteady when they tip their heads
back to look
>up, sometimes BPPV is called "top shelf vertigo." Women with BPPV may find
that the
>use of hair dryers in beauty parlors brings on symptoms. An intermittent
pattern is the
>usual situation. BPPV may be present for a few weeks, then stop, then come
back again.
>WHAT CAUSES BPPV?  The most common cause of BPPV in people under age 50
>is head injury. In older people, the most common cause is degeneration of
the vestibular
>system of the inner ear. However, in perhaps half of all cases, BPPV is called
>"idiopathic," which means it occurs for no known reason. 
>HOW IS THE DIAGNOSIS OF BPPV MADE?  Your physician can make the
>diagnosis based on your history, findings on physical examination, and the
results of
>vestibular and auditory tests. Blood pressure will be checked lying flat
and standing.
>Other diagnostic studies may be required. An ENG may be needed to look for the
>characteristic nystagmus (jumping of the eyes). An MRI scan will be
performed if there is
>any possibility of a stroke or brain tumor. A rotatory chair test may be
used for difficult
>diagnostic problems. It is possible to have BPPV in both ears (bilateral),
which may
>make diagnosis and treatment more challenging.
>HOW MIGHT BPPV AFFECT MY LIFE?  Certain modifications in your daily
>activities may be necessary to cope with your dizziness. Use two or more
pillows at night.
>Avoid sleeping on the "bad" side. In the morning, get up slowly and sit on
the edge of
>the bed for a minute. Avoid bending down to pick up things, and extending
the head,
>such as to get something out of a cabinet. Be careful when at the dentist's
office, beauty
>parlor, or in sports activities or positions where the head is flat or
>HOW IS BPPV TREATED?  BPPV has often been described as "self-limiting"
>because symptoms often subside or disappear within six months of onset.
Symptoms tend
>to wax and wane. Motion sickness medications are sometimes helpful in
controlling the
>nausea associated with BPPV but are otherwise rarely effective. However,
various kinds
>of physical maneuvers and exercises have proved effective. Three varieties of
>conservative treatment, which involve exercises, and a treatment that
involves surgery are
>described on the next page.
>This list contains people who are known for treating BPPV.
>Physical Treatments
>Midwest:              Dr. T. Hain (Northwestern Memorial Hospital, Chicago,
>                      Dr. N. Shepard (Taubman Medical Center, Ann Arbor,
>West Coast:           Dr. J. Epley (Portland Otologic Clinic, Portland, Oregon)
>                      Dr. F. Black (Dow Neurological Institute, Portland,
>                      Dr. R. Baloh (UCLA, Los Angeles, California)
>Mountain States:      Dr. I. Arenberg (Denver, Colorado)
>East Coast:           Dr. D. Zee (Johns Hopkins Hospital, Baltimore, Maryland)
>South:                Dr. S. Herdman (Miami, Florida)
>                      Dr. J. Li (Palm Beach Gardens, Florida)
>                      Dr. R. Steenerson (Atlanta, Georgia)
>                      Dr. J. Soileau (Baton Rouge, Louisiana)
>                      Kathleen Deyo, P.T. (Houston, Texas)
>Canada:               Dr. L. Parnes (London, Ontario)
>Europe:               Dr. A. Semont (Paris, France)
>Europe:               Dr. J. Juvanon (Nemours, France)
>(The Epley and Semont Maneuvers)
>There are two treatments of
>BPPV that are usually
>performed in the doctor's
>office. Both are very effective,
>with roughly an 80% cure rate,
>according to a study by
>Herdman and others (1993).
>The maneuvers are named after
>their inventors. They are both
>intended to move debris or "ear
>rocks" out of the sensitive back
>part of the ear (posterior canal)
>to a less sensitive location. Both
>maneuvers take about 15
>minutes to accomplish. The
>Semont maneuver (also called
>the "liberatory" maneuver)
>involves a procedure whereby
>the patient is rapidly moved
>from lying on one side to the other. The Epley maneuver (also called the
>repositioning, canalith repositioning procedure, and modified liberatory
maneuver) is
>shown in the figure above. It involves sequential movement of the head into
>positions. The recurrence rate for BPPV after these maneuvers is about 5
percent, and in
>some instances a second treatment may be necessary. 
>After either of these maneuvers, you should be prepared to follow the
instructions below,
>which are aimed at reducing the chance that debris might fall back into the
>back part of the ear. 
>(Epley or Semont Maneuvers) 
>1. Wait for 10 minutes after the maneuver is performed before going home.
This is to avoid
>"quick spins," or brief bursts of vertigo as debris re-positions itself
immediately after the
>maneuver. Don't drive home yourself; have someone else drive you.
>2. Sleep semi-recumbent for the next two days. This means sleep with your
head halfway
>between being flat and upright (a 45 degree angle). This is most easily
done by using a
>recliner chair or by using pillows arranged on a couch. During the day, try
to keep your
>head vertical. You must not go to the hairdresser or dentist. No exercise
which requires
>head movement. When men shave under their chins, they should bend their bodies
>forward in order to keep their head vertical. If eyedrops are required, try
to put them in
>without tilting the head back. Shampoo only under the shower. 
>3. For at least 1 week, avoid provoking head positions that might bring
this on again.
>       Use two pillows when you sleep.
>       Avoid sleeping on the "bad" side.
>       Don't turn your head far up or far down.
>       Be careful to avoid head-extended position, in which you are lying
on your back,
>       especially with your head turned towards the bad side. This means be
cautious at
>       the beauty parlor, dentist's office, and if having minor surgery
done. Ask them to
>       keep you as upright as possible. If appropriate, exercises for
low-back pain should
>       be stopped for a week. No "sit-ups" for at least one week. No
"crawl" swimming.
>       (Breast stroke is OK.)
>       Avoid far head-forward positions such as might occur in certain
>       (i.e. touching the toes). 
>4. At one week after treatment, put yourself in the position that usually
makes you dizzy.
>Position yourself cautiously and under conditions in which you can't fall
or hurt yourself.
>Let your doctor know how you did.
>WHAT IF THE MANEUVERS DON'T WORK?  These maneuvers don't always work
>(only 80% of the time), and if they don't, then your doctor may wish you to
proceed with
>the Brandt-Daroff exercises, as described below. If a maneuver works but
>recur or the response is only partial, another trial of the maneuver might
>(Brandt-Daroff Exercises)
>The Brandt-Daroff Exercises
>are a second method of treating
>BPPV, usually used when the
>office treatment fails. They
>succeed in 95% of cases but are 
>more arduous. These exercises
>are performed in three sets per
>day for two weeks. In each set,
>one performs the maneuver
>below five times. 
>1 rep = maneuver done to each side in turn (takes 2 minutes)
>Suggested Schedule:
>Time           Exercise       Duration
>Morning        5 reps         10 min
>Noon           5 reps         10 min
>Evening        5 reps         10 min
>One starts upright. Then, one moves into the side-lying position, with the
head angled
>upward about half way. An easy way to remember this is to imagine someone
standing in
>front of you, and just keep looking at their head at all times. Stay in the
>position for 30 seconds, or until the dizziness subsides if this is longer,
then go back to
>the sitting position. Stay there for 30 seconds, and then go to the
opposite side in the
>same way.
>If, during a session, the exercise fails to produce symptoms, stop the
exercises for that
>day. If no symptoms can be produced during the first session of the next
day, then stop
>the exercises entirely. In most persons, complete relief from symptoms is
obtained by one
>week. The Brandt-Daroff exercises as well as the Semont and Epley maneuvers are
>compared in an article by Brandt (1994), listed in the reference section.
>(Posterior Canal Plugging)
>If exercises are ineffective in controlling symptoms and they have
persisted for a year or
>longer, a surgical procedure called "canal plugging" may be recommended. Canal
>plugging completely stops the posterior canal's function without affecting
the functions of
>the other canals or parts of the ear. This procedure poses a small risk to
>Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional
vertigo, Arch
>Otolaryngol, 1980, 106:484-485 (Brandt-Daroff Exercises)
>Brandt T, Steddin S, Daroff RB. Therapy for benign paroxysmal positioning
>revisited. Neurology 1994, 44:796-800
>Epley JM. The canalith repositioning procedure: For treatment of benign
>positional vertigo. Otol Head Neck Surg 1992: 107: 399-404 (Epley Maneuver)
>Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign
>positional vertigo: incidence and prognosis in a population-based study in
>county, Minnesota. Mayo Clinic Proc, 66, 1991, 596-602
>Harvey S, Hain T, Adamiec L. Modified liberatory maneuver: effective
treatment for
>benign paroxysmal positional vertigo. Laryngoscope 104: October 1994 (Epley
>Herdman, S. Treatment of benign paroxysmal vertigo, Physical Therapy 70,
1990, 381-388
>(All maneuvers)
>Herdman S, Tusa R, Zee D, Proctor LR, Mattox DE. Single treatment approaches to
>benign paroxysmal positional vertigo. Arch Otol Head Neck Surg 1993,
>(Epley and Semont maneuvers)
>Parnes LS, McClure JA. Posterior semicircular canal occlusion for
intractable benign 
>paroxysmal positional vertigo. Ann Otol Rhinol Laryngol 1990, 99:330-334
>Parnes LS, Price-Jones RG. Particle repositioning maneuver for benign
>positional vertigo. Ann Otol Rhinol Laryngol 1993,102:325-331 (Epley maneuver)
>Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory maneuver. Adv
>Otolaryngol 1988, 42, 290-293 (Semont Maneuver)
>Welling DB, Barnes DE. Particle Repositioning maneuver for benign paroxysmal
>positional vertigo. Laryngoscope 104; 1994, 946-949 (Epley Maneuver)
>Rev. 10-17-96


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