1. Dix-Hallpike Maneuver Test
• This is indicated for Benign Paroxysmal Positional Vertigo
• Starting Position: Long-sitting such that the head faces forward and will be suspended from the examining bed when placed in supine; head should be supported by the examiner throughout the test
• Second Maneuver would be: Head rotated to the right side, shift again from sitting to supine and then back to sitting after 60 secs maintaining rotated position
• Third Maneuver is: head rotated to left side and repeat above changes in position
• If it’s a positive test then Nystagmus is seen ( The reason behind is the rapid change causes reorientation of the posterior semicircular canal and ampulla, producing gravity dependent endolymph and cupula motion. Presence of the otholitic lesion increases the sensitivity of canal to above movement tht causes nystagmus

Here are some of the exercises for BPPV:

1. Epley’s Canalith-repostioning Maneuver also known as Canalith-Repositioning Procedure
a. First line of treatment for BPPV
b. Position : sitting with head upright
c. Assume Dix-Hallpike provoking position. You have to observe the nystagmus until it stops. Massager is held into the mastoid region or downward ear to facilitate ampullofugal flow of endolymph. Wait for another 30secs to watch again for nystagmus. Entire process takes about 3-4mins.
d. The examiner now turns the patient’s head to the opposite side while keeping the head extended ( Dix-Hallpike) and waits additional 30 secs after nystagmus stops. Massager again on the mastoid bone of downward ear and process repeated. In Dix-Hallpike positions B & C nystagmus beats toward upward ear.
e. Head and trunk positions maintained, and patient rolls into right lateral position. In this position D, head is turned 180 degrees opposite to that with respect to position B. Apply massager to mastoid and wait 30secs, nystagmus beat towards upward ear.
f. Maintain head position, bring patient rapidly to sitting, rotate head forward and wait 1 min.-position E.
g. Stop procedure after 2 cycles if nystagmus or dizziness tops, Otherwise, repeat maximum of 6 cycles with each cycle lasting 3 mins. Whole process last 20-30 mins.
h. After test, patient rests in semirecumbent position at 45 degrees angle for 2 dyas without movement of head up ro down. Patient is also advised to sleep with affected side up, using 2 pillows, and to avoid symptom provoking positions for 1 week.

2. Sermont Maneuver
a. Indication: Used when affected side is known
b. Starting position: Patient sits with head turned 45 degrees head position to affected side ( this orients posterior canal from posterolateral to lateral direction)
c. Movement: Patient moved to side-lying on affected side while keeping the 45 degrees angle head position, maintain for 2-3 mins ( provoke vertigo) –the posterolateral canal faces vertically down and induces gravity-dependent motion
d. Next shift to opposite side-lying maintaining head position if there’s no vertigo, maintain the position for 5 mins, shake head once or twice to free otolithic debris then slowly bring patient back to sitting
e. Post exercise care- patient remains vertical for next 2 days and avoid symptom provoking positions for one week.

3. Brandt-Daroff Exercise
a. Indication: Used for a home exercise treatment program for BPPV
b. Principle: Otoconial material in cupula or posterior semicircular canal ( cupulolithiasis)
can be dislodged by frequently moving the paitent in a vertigo-provoking symptom.
Repeatedly placing the patient on symptom free provoking symptom will fatigue the
Response and stimulate the CNS to compensate by habituating and adaptation.
c. Starting position: Sitting on the edge of the bed ( posterior canal faces posterolaterally at
45 degrees)
d. Maneuver: Quickly move to right side-lying position wit head rotated 45 degrees facing
up (posterior canal oriented vertically downward) if it causes vertigo then hold for 30secs
AFTER vertigo stops, go back to starting position and hold for 30secs. And then rapidly
Move to the left side-lying position with head rotated 45 degrees facing up maintaining
This for 30 secs AFTER vertigo stops ( right posterior canal directed horizontally; left
Posterior canal oriented vertically)
d. Frequency: Repeat 5-10 times per session, 3X/day for several weeks
e. If symptoms persists for one year, consider surgery

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