Introduction

Paroxysmal positional vertigo (PPV) is a form of vertigo associated with short-term episodes of sudden-onset vertigo triggered by changes in head position. PPV is a vestibular disorder, which simply refers to disorders that affect your balance. 

Fluid-filled structures within our ears called the semicircular canals, play an important role in maintaining our balance. The fluid, known as endolymph, flows with the movement of our head, the speed and motion of the endolyph is detected by sensory cells that send signals to the brain and this sensory information is used to keep our balance. PPV is caused by small calcium carbonate crystals coming loose within the endolymph and disrupting its flow. 

PPV isn't particularly harmful, however, the symptoms can be distressing and uncomfortable. Ultimately, it can negatively affect quality of life, significantly impacting emotional, physical, and social well-being. 

Physical impact

Balance and mobility

The primary symptom of PPV is an abrupt sensation of dizziness or spinning. This can significantly impact balance and coordination, affecting basic physical activity and movement such as standing, walking, or even repositioning yourself in bed or whilst sitting. At its worst, this can manifest dangerously by increasing the risk of falls. 

Due to lapses in balance, PPV patients are exposed to a higher risk of slipping, tripping, and falling, and thus injuries ranging from slight bruising to critical fractures or head injuries. 

This is notably concerning amongst elderly populations, who are more likely to be seriously injured from a fall. Although falls can happen to anyone and are a common and serious potential outcome of PPV, the research indicates that the elderly are the worst affected.¹

Sleep disturbances 

Sleep disturbances are a significant consequence of PPV. When lying down, movements such as turning over or sitting up can often elicit incidents of vertigo. This can be particularly distressing as it prevents becoming comfortable enough to fall asleep. Sleep disruption is commonly reported amongst patients with PPV, and contributes to a decline in physical and mental health².

Prevention of good quality sleep may lead to sleep deprivation and associated symptoms such as general fatigue and lethargy, negative impacts on your mood, irritability, and impaired cognitive function. 

Emotional and psychological impact 

Anxiety and depression 

Patients with PPV often find it difficult to predict and when episodes of vertigo may happen. This uncertainty can lead to persistent fears and anxiety over when the symptoms will occur. Furthermore, this can trigger feelings of frustration and helplessness due to feeling as if you have little control over the condition and the subsequent prevention of everyday tasks that can ensue when symptoms appear. 

Over the long term, these emotional reactions to the condition can negatively affect the mental health of patients and progress to mood disorders such as clinical depression or anxiety. This is an important side effect to be aware of, as patients with PPV are affected by anxiety and depression mood disorders at a rate disproportionately higher than the general population.³

Social isolation

In severe cases, the debilitating nature of PPV may prevent patients from feeling comfortable taking part in social activities. Some PPV patients may feel anxious about experiencing symptoms in public and certain physical activities may become dangerous if symptoms were to occur. 

Ultimately, this can result in avoidance behaviours and social isolation, reducing support from family and friends and increasing the risk of feelings of depression and loneliness. The impact of PPV on patients' social lives is observed by research, with many patients reporting a lack of social engagement compared to before they developed symptoms and a subsequent lower overall satisfaction with life.⁴

Occupational impact

Work performance employment stability

The adverse effects of PPV on patients' lives can unfortunately also have ramifications on their professional work. Symptoms such as dizziness and imbalance can impair your ability to complete certain tasks and reduce concentration and overall productivity. Depending on the nature of their job, in severe cases, patients may need to take frequent sick leave or leave their role altogether. 

Chronic PPV may make long-term employment difficult to achieve if the effects are severe enough to significantly impact a patient's ability to operate within conventional working conditions. In many cases, employers should be able to accommodate conditions such as PPV, allowing patients to achieve and maintain a full and positive career. 

However, unfortunately, patients may still suffer employment instability causing financial strain and decreased satisfaction within their professional and personal lives. There is evidence that patients with PPV may suffer substantial economic loss and burden due to a reduced ability to work, as well as the financial costs associated with managing the condition⁵.

Management and treatment

Thankfully, there are methods to manage PPV that can be effective and improve the quality of life for patients.

Vestibular rehabilitation therapy

Vestibular rehabilitation therapy (VRT) involves performing exercises that are designed to improve stability and balance, and reduce dizziness. The idea is that through these exercises,  patients can retrain their brains to adjust their sense of balance by accounting for the unusual signals caused by the calcium carbonate crystals that disrupt the flow of endolymph. 

There is evidence that VRT can significantly improve PPV symptoms and subsequently improve the quality of life of patients.⁶

Canalith repositioning manoeuvres

Canalith reposition manoeuvres (CRMs) can be used to effectively treat PPV, they involve manoeuvering the head to guide the calcium carbonate crystals so that they return to their original, correct positions within the inner ear. A common example is the Epley manoeuvre, which is simply a pattern of moving your head from one side to the other while changing from a laying to a sitting-up position. 

CRMs have demonstrated high efficacy in alleviating PPV symptoms and research has highlighted in particular the success of the Epley manoeuvre in providing immediate and sustained relief amongst patients.⁷

Medications and surgical options

Medication can be used to manage symptoms, such as anti-nausea medication or vestibular suppressants. These simply target the symptoms of the condition, however, and do not effectively treat the underlying cause of PVV. Therefore, medications are typically only used for short-term symptomatic relief. 

In particularly very serious cases where the impact on quality of life is severe and other treatments have not worked, surgical intervention may be considered. An operation option may be a semicircular canal occlusion, whereby an incision is made behind the ear so the surgeon can operate on the semicircular canal. 

Long-term prognosis and quality of life 

Recurrence and chronicity 

Unfortunately, PPV is associated with high recurrence rates, with patients typically experiencing multiple recurring episodes throughout their lives. Combined with the sudden and unpredictable nature of symptom onset, this can make managing symptoms and maintaining a consistent quality of life difficult. 

Long-term studies indicate that while treatment can provide temporary relief and significantly improve quality of life, it is important to be aware that reoccurrences can happen and to be ready for repeated treatment and intervention.⁸

Although patients with PPV face many challenges, it is possible to develop effective strategies to consistently and effectively alleviate symptoms by adopting the right treatments. Other ways to manage the condition are to learn potential triggers and how to avoid them, use assistive mobility devices, and seek the help and guidance of support groups and healthcare professionals.

Conclusion 

PPV can have a significant impact on the quality of life of patients, affecting their physical, mental, and emotional well-being. The unpredictable and sudden onset of symptoms, such as dizziness and spinning, can impair mobility and the ability to take part in certain social activities. It also has the potential to hinder a patient's professional career. These aspects can negatively affect the patient's mental health.

However, the condition can be effectively managed through treatments such as vestibular rehabilitation therapy and canalith repositioning therapy, both of which have high levels of efficacy in alleviating symptoms. Other options are medications for short-term relief, and surgery in severe cases where other treatment options have failed.

Unfortunately, the condition can be chronic, with a high chance of a patient experiencing multiple recurrences throughout their lifetime. Thus effective long-term management of the condition requires ongoing preparation and attention.