Welcome to Dr. Li's BPPV /CRP page!
Benign Paroxsysmal Positional Vertigo, Benign Positional Vertigo, Positional Vertigo, BPPV or BPV are the many names for a condition that troubles many patients.
What is Benign paroxysmal positional vertigo? (BPPV) is a type of dizziness caused by abnormal reaction of the balance organ to certain head movements. They are brought on by placing the affected ear downward. In some cases any head movement will aggravate the symptoms.
What causes it? In simple conceptual terms, there are crystals that occur normally in the inner ear. When these crystals are displaced into the semicircular canals, they can stimulate the balance nerve inappropriately. When the head is placed in certain positions, a severe spinning sensation is produced. Although the spinning sensation usually lasts about 20 seconds, it is often severe and can produce unsteadiness and nausea which may last several hours.
How is it diagnosed? It is important to realize that the diagnosis of the cause of vertigo can be most difficult. After a thorough history and physical, many tests may need to be done to differentiate the various types of vertigo. These tests range from blood tests to tests of inner ear function. When BPPV occurs, there is an involuntary movement of the eyes called nystagmus which occurs. To make the diagnosis, the patient's head is placed into certain positions and the eye movements are recorded with an electronic monitor (ENG) and/or observed.
How is it treated?
Is the canalith repositioning procedure is a safe and effective procedure? Yes!!! It is nonsurgical, painless and has few if any side effects. In our experience more than 95% of patients experience a significant nearly-immediate improvement. Sometimes patients may experience mild transient vertigo for a few days afterwards.
How is it done? During the procedure, the canalith crystals suspended into the solution of the inner ear with an oscillating machine strapped behind the affected ear. The appropriate head positions are effected to cause the crystals to be repositioned to an area away from the balance nerve receptors. This is often done under ENG guidance to ensure the procedure is being done at the appropriate pace. The procedure usually takes about 10-20 minutes. 95% cure is usually obtained as an end result although some patients need to be treated more than once.
If it is so simple, why haven't I heard about this before? Great question. For some strange reason, CRP has been slow to catch on -- It seems too good to be true. In seminars given by Dr. John Epley and Dr. John Li, there have been many "doubters and Naysayers" that have been "converted". An interesting editorial letter was written to the publication Otolaryngology Head and Neck Surgery in response to one of my CRP manuscripts deriding CRP as "Hocus Pocus".
More Detailed Information On BPPV and the Canalith Repositioning Procedure (CRP)-- a.k.a. The Epley Manuver. Please note that CRP is very different from the Semont manuver which we find too forceful for practical use. To learn more about CRP contact:
Courses offered:
How is it done? The following is part of our on-line manual. Check out Dr. Epley's Video!
In Optimized CRP, pre-medication to prevent nausea or vomiting is usually
not necessary except in severely affected anxious patients. The patient
begins the procedure in a sitting position. The head is turned toward the
affected side. A mastoid bone oscillator is applied and held in position
to the mastoid of the affected ear by a head band. This frees up the operator
to help with patient positioning. (The headband is applied such that the
velcro straps are over the occiput. The oscillator is then slipped under
the band on the affected side.) 
The patient is then slowly reclined to the Dix-Hallpike position of
the affected side. The rate is titrated to the point of no nystagmus and
no symptoms. This usually takes about 40 seconds. Another 20 seconds are
spent in that Dix-Hallpike position (affected ear down). 
Next, the patient's head is slowly turned to the opposite side and the body rolled such that the shoulders are aligned perpendicularly to the floor (affected ear up). The head is then turned further so that the nose points 30 degrees below the plane of the chair. This usually takes another 40 seconds.
If no nystagmus
is seen, the patient is then raised back to the sitting position. Finally,
the head is turned back to the midline. These positions are demonstrated
in Fig. 1. A Dix-Hallpike test is done immediately following the procedure.
If nystagmus is seen, the procedure is repeated. After the procedure the
patient is instructed to avoid agitation of the head for about 48 hours
while the particles settle. The are also asked to return in one week for
follow-up exam.
Pointers: The specially designed headband holds a model of the posterior
semicircular canal containing simulated canaliths. The model is spatially
oriented to approximate the position of the actual (ipsilateral) posterior
semicircular canal. By watching the particles flowing within the model,
a novice operator (or even the patient) can have instant feedback as to
the effect each repositioning maneuver has on the canalithiasis. If done
correctly, the particles should flow in the direction marked by the arrows
on the headband from the start position (representing the nerve filled
ampulla of the posterior semicircular canal) to the end position (representing
the vestibule in which the particles cannot irritate any nerve structures).
Care should be taken to prevent reflux (movement opposite to arrows) of
particles back to the ampulla.
Rather than going suddenly from position to position , an emphasis is made on moving the patient gradually, at a pace that does not generate any rotatory nystagmus. If nystagmus is induced, motion is suspended until the nystagmus goes away. The gradual (rather than sudden) change in head position prevents "fluid lock". A simple example of fluid lock can be demonstrated in a ketchup or salad dressing bottle. The viscous fluid flows better when gradually tilted to an angle than when suddenly inverted. When the fluid does flow after sudden inversion, it occurs somewhat more violently. In the inner ear, this turbulent movement of canaliths seems to cause the dizziness. Slow deliberate movements avoids this dizziness and is preferred by patients. Constant mastoid vibration seems to help the canaliths move within the semicircular canals much like shaking the ketchup bottle helps the flow of ketchup. The mechanically reclining chair is helpful in accomplishing the gradual position changes since most patients do not have the abdominal muscle strength required to slowly recline unsupported. Foot pedals are quite helpful since the operator often has his hands full.
We have developed a system for doing CRP. This has been packaged as
a kit by Medical Surgical Innovations (- a cottage industry that does
not give me a kick back for selling their "product")
Diagram demonstrating path of the particles.
Movie: Awaiting file conversion see diagram for now.
Dr. Li's BPPV Articles:
"Mastoid Oscillation, a Critical Factor for Success in the Canalith Repositioning Procedure." by John C. Li, M.D.
The canalith repositioning procedure (CRP) has recently gained controversial recognition as a treatment for benign paroxysmal positional vertigo (BPPV). Some authors contend that CRP is no more effective than no treatment at all. Unfortunately, its technique has not been uniformly applied nor its outcomes uniformly assessed. The author has found the use of mastoid oscillation critical in the success of this procedure. Another important factor is the time interval between diagnosis and relief of symptoms. Since it is well known that BPPV can spontaneously resolve after many months, the time frame for comparison should be short. A one week time interval was chosen for study purposes. Sixty patients were randomized to three initial groups. The control group (23) was not given any treatment. A second group (27) was given treatment with CRP with mastoid vibration. A third group (10) was assigned to receive CRP without mastoid vibration. Resolution was defined as no symptoms and a negative Dix-Hallpike test. The results showed that none of the control group resolved completely in one week. Although 60% of those that received CRP without mastoid vibration felt improved, none were nystagmus-free. An overwhelming 92% of those that received CRP with mastoid vibration felt improved and 70% were free of rotatory nystagmus after only one treatment. A review of all patients diagnosed with BPPV and treated using CRP with mastoid vibration was also undertaken. In a series of 67 patients with a minimum of four week follow-up, only two have not responded to CRP yielding a 97% rate of symptom control.
"THE COST EFFECTIVENESS OF THE CANALITH REPOSITIONING PROCEDURE"
One hundred patient who had undergone the Canalith Repositioning Procedure for the treatment of benign positional vertigo were surveyed with regard to the financial impact of their disease. They were questioned regarding the number of physicians they saw, the types of specialty they were required to visit prior to diagnosis of this condition. They were asked to tabulate the various forms of diagnostic testing including audiograms, ABR's, ENG's, CT scanning and MRI scanning. They were asked to determine the amount of time lost from work and the impact on their social lives. They were asked to estimate the sum of all diagnostics and disease related expenses. The average financial impact of benign positional vertigo on these patients totalled $2,594. Since the Canalith Repositioning Procedure is relatively inexpensive and can obviate much of these expenses in at least 95% of the patients, we believe that it is very cost effective and should be incorporated into routine practice.
"Optimized CRP"
abstract withheld pending publication
"Controversies in the Treatment of Benign Positional Vertigo"
abstract withheld pending publication
If CRP is so simple, why haven't I heard about this before? Excerpts from a "CRP unbeliever"
Dear Dr. Neely: Editor: Otolaryngology-Head and Neck Surgery July 10, 1995
Dr. Li's recent paper about the value of mastoid oscillation and the canalith maneuver in treatment of benign positional vertigo1 (BPV) deserves comment. The main contention of the paper is that the use of a vibrator applied to the subject's mastoid during the canalith maneuver will usually "cure" BPV. Dr. Li states that he was motivated to write his paper in response to mine for which I did not use a vibrator2.
It is difficult to take the vibrator seriously. With no consideration of the physical situation involved in solid objects falling through a small fluid-filled, curved canal, Li and other authors have used different vibrators as available. They employ different frequencies of stimulation at different amplitudes in whatever manner each~author thinks they should be used. All are reported to "work. " I see no reason to believe that vibrators are other than a magic wand - a physical prop used to add mysticism to an implausible event to enhance its credibility.........The most interesting aspect of Li's paper is the untreated control group, NONE of whom improved. In contrast, the literature indicates that the majority of patients with BPV improve Spontaneously. Different authors use different time frames and descriptions, making direct comparisons difficult. In my study I found that the symptoms of 50% of controls were either all or essentially gone after one month............. I have no reason to believe that Dr. Li's findings are not sincere, yet clearly, there is a problem. Perhaps we are not looking at the same disease. Perhaps some other reason will explain the differences. We must try to resolve this discrepancy. Do other clinicians now find that BPV never improves spontaneously as Li reports? Time and further reports will tell. .......For the otolaryngologist who believes that this issue doesn't affect him or her I offer a final thought. It relates to the manner in which our specialty handles dizziness in general, but particularly the canalith maneuver. I believe that our credibility is damaged more than we realize when we embrace weird theories on flimsy evidence or adopt treatments without good reason. If the canalith story is characteristic of the depth of thought that we employ, is there any reason to respect us? Should the public trust us?
Dr. X, M.D., Ph.D.
The following is in response to Dr. X's editorial letter:
I absolutely agree with Dr. X that it is difficult to take the mastoid vibrator seriously. Even the name invokes a few chuckles (which is why I prefer the term mastoid oscillation). The first few times I tried CRP, with mastoid oscillation, the patients and I laughed through the entire procedure, joking about the voodoo medicine we were performing. But to our surprise, almost everyone came back with incredulous stories of how they were completely cured of their problems. Their results were all the more extraordinary because they came after numerous physician consults combined with failed watchful waiting and/or oral vestibulosuppressant therapy.
From that point on we became a referral center for BPPV and have, to date, maintained at least a 95% "cure" rate (abolition of rotary nystagmus and symptoms). Since many of our patients were referred for CRP and expected to receive it, there was some difficulty in creating a control group. We were able to create this control group by staving off the procedure for a week or two rather than immediately performing CRP on the day of the patient's visit. This means that our "controls" reflect the a one week interval change of patients who presented with BPPV symptoms serious enough to warrant treatment.
Dr. X states that "NONE" of my patients in the untreated control group improved. This is not quite true. One patient in this group did report a marked improvement, however, classic nystagmus was found on Dix Hallpike testing. My time interval for reevaluation was one week. Had I used one month, or even six months, the my numbers would, of course, reflect more closely the spontaneous remission rate. I have also found that merely asking patients about their dizzy spells is quite inaccurate. BPPV patients learn to avoid activities that provoke dizziness. Detailed questioning is necessary and Dix Hallpike testing should be done to confirm improvement.
Consider the hypothetical controversy of treating a deep laceration with sutures vs. waiting for spontaneous closure. If you check the wounds from each group in a month or two, chances are that they would be healed, and one might conclude that sutures are worthless because wounds can close by themselves. However, if checked within a one week interval, the sutured vs. no treatment wound groups would differ vastly. The conclusion that sutures are worthwhile should be obvious. One must naturally develop criterion regarding depth of lacerations to be sutured; likewise, criterion regarding severity of vertigo and disability will determine which patients receive CRP.
As far as the comment on "weird theories" is concerned, I would agree that to an uneducated lay person, the idea that strapping on a oscillating contraption while being placed in various contortions would seem farfetched. However, there is a reasonable scientific basis for this procedure's success. I would also point out that every scientific advance has had its contingency of detractors. If we close our minds to progress we would live in a world without vaccines, antibiotics, electricity, etc. and perhaps still believe that the earth was flat.
The bottom line is that the technique of CRP with mastoid oscillation works well. From the time they leave the office, 95% of patients presenting with BPPV are immediately improved. They no longer need to live with horrible vertigo symptoms for weeks, months or years. They do not need to consult a multitude of physicians and waste health care dollars.
I challenge any physician to simply try the techniques of CRP with the use of a mastoid oscillator. My results should be easily reproducible.
Sincerely,
John Li, MD
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