Archives of Gerontology and Geriatrics 49 Suppl. 2 (2009) S50–S54

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Clinical features of benign paroxysmal positional vertigo (BPPV) in Taiwan:

differences between young and senior age groups

Chung-Lan Kaoa,b,c, *, Wan-Ling Hsieha,c, Chang-Ming Chernb,d, Liang-Kung Chenb,c,e, Ming-Hsien Linb,c,e,Rai-Chi Chana,b

aDepartment of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Shih-Pai Road, Section 2, 11217, Taipei, TaiwanbSchool of Medicine, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei, 11221, TaiwancCenter for Geriatrics and Gerontology, Taipei Veterans General Hospital, Shih-Pai Road, Section 2, 11217, Taipei, TaiwandDepartment of Neurology, Taipei Veterans General Hospital, Shih-Pai Road, Section 2, 11217, Taipei, TaiwaneDepartment of Family Medicine, Taipei Veterans General Hospital, Shih-Pai Road, Section 2, 11217, Taipei, Taiwan

a r t i c l e i n f o

Keywords:

Benign paroxysmal positional vertigo

Canalith repositioning procedure

Life quality

a b s t r a c t

BPPV is a common cause of vertigo. Several treatment procedures can facilitate recovery. In

this study, we aimed to identify the demographic features, resolution and recurrence rates and

impacts on daily activities in BPPV patient between young and senior age groups in Taiwan. This

retrospective study recruited 218 patients of BPPV. Medical history, canal involvement, treatment

required for complete resolution, symptom free period and recurrence rates were evaluated

between the two age groups. Up to 80.7% of patients were successfully treated by a single treatment.

For patients aged more than 65 years, the recurrence rate was 1.7 times higher than that in the

younger age group (p =0.07). The symptom-free period before recurrence was nearly 2.2 times

longer in the senior age group (p =0.03). Work-related activities were influenced more by BPPV in

the younger age group (p =0.03). We conclude that BPPV is prone to occur and recur in people of

senior age. Clinicians should have the knowledge to diagnose different types of BPPV and treat it

accordingly to prevent further complications.

© 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

BPPV is one of the most common causes of vertigo. It is estimated

that BPPV accounts for 20–30% of all vertigo (Baloh et al., 1989;

Neuhauser et al., 2001; Yimtae et al., 2003). BPPV is characterized by

a sudden, brief period of vertigo when the patient’s head is moved

into a position in the affected semicircular canal. Although benign

in nature, BPPV can cause physical and psychological hazards in

patients’ daily activities (Lopez-Escamez et al., 2005). Fall accidents

resulted from vertiginous attacks in BPPV may subsequently

lead to further morbidity and disability. Even though BPPV may

resolve spontaneously, this sudden, unexpected symptom may be

frightening, and the relative immobilization period due to fear of

falling can cause secondary comorbidity, especially in the senior

age group. Therefore, it is crucial for the clinicians to accurately and

promptly diagnose and treat BPPV to reduce complications such as

fractures, immobility and muscle atrophy.

Several factors apparently predispose people to BPPV. They

include advanced age, head and neck trauma, inactivity, and other

ear diseases or surgeries (Steenerson et al., 2005). There are

* Corresponding author. C-L. Kao, Department of Physical Medicine

and Rehabilitation, Taipei Veterans General Hospital, Shih-Pai Road,

Section 2, 11217, Taipei, Taiwan.

Tel.: +(886-2) 28757363; fax: +(886-2) 28757359.

E-mail address: clkao@vghtpe.gov.tw (C-L. Kao).

two theories explaining the mechanisms of BPPV. The original

Schukencht’s “cupulolithiasis” theory (Schuknecht, 1969), attributes

the pathophysiology of BPPV to debris adhering to cupula. This

type of BPPV is less responsive to treatment maneuvers (Fife

et al., 2008). The “canalolithiasis” theory holds the view that the

mechanism of BPPV results from free floating clots trapped in the

ampullofugal branch of the semicircular canals. Whenever there are

head movements, the clots gravitate to the most dependent part

of the canal. The resultant endolymphatic flow causes vertigo and

nystagmus (Hall et al., 1979).

Several procedures are reported to be effective in the treatment

of BPPV. Based on the theory of cupulolithiasis, Brandt and

Daroff (1980) developed the first effective physical therapy of

redistribution exercise. Semont et al. (1988) introduced a liberatory

maneuver which cured 92.68% of BPPV patients, with only 4.22%

experiencing recurrences. The canalith repositioning procedure

(CRP), with several modifications since Epley’s original description

(Epley, 2001), has become a mainstay of treatment of posterior

canal BPPV (PC BPPV). Another procedure, so-called Lempert or

“barbeque” maneuver, was developed for the treatment of a BPPV

variant involving horizontal canal (HC) (Lempert and Tiel-Wilck,

1996). The purpose of this study was to identify the demographic

features, canal involvement, resolution and recurrence rates of BPPV

in Taiwan. We also attempted to answer questions about what

0167-4943 /$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.

C-L. Kao et al. / Archives of Gerontology and Geriatrics 49 (2009) S50–S54 S51

differences exist in BPPV recurrence rates and impacts on daily

activities between young and senior age groups of the population.

2. Subjects and methods

2.1. The study sample

We retrospectively reviewed all BPPV patients who had received

treatment at the Department of Physical Medicine & Rehabilitation,

Taipei Veterans General Hospital between November, 2001 and

April, 2009. This research followed tenets of Declaration of Helsinki.

Past history including head trauma, falls and Meniere’s disease were

reviewed. Information about how dizziness had affected their work,

household and social activities were evaluated by subjects’ self-

rated questionnaires on their first visits.

2.2. Diagnosis

Diagnosis of BPPV was based on the patient’s history, subjective

symptom reports, and objective findings of Dix–Hallpike testing

(sensitivity 82%, specificity 71%) (Lopez-Escamez et al., 2000).

Patients with PC involvement typically reported vertigo when

lying down, rising up from bed, bending forward or tilting their

heads to reach overhead; and patients with HC involvement often

reported vertigo during rolling in bed or horizontal head movement

in the upright position (Steenerson et al., 2005). Each patient’s

semicircular canal involvement was determined by the direction

of nystagmus shown on the infra-red video fixation-block goggles

(Micromedical Computerized Real Eyes infrared video frenzel with

single, pivotal camera, Micromedical Technologies, Illinois, USA)

in the Dix-Hallpike position. An upbeat nystagmus with torsional

component towards the inferior ear confirmed the diagnosis of

PC BPPV. Patients with geotropic (canalolithaisis) or ageotropic

nystagmus (cupulolithiasis) were diagnosed as HC BPPV. Subjects

were grouped into posterior or horizontal canal involvement

on right side, left side or bilateral involvement. Patients who

had geotropic/ageotropic nystagmus in the roll test and torsional

nystamgus upon Hallpike maneuver were grouped as having two-

canal involvement. Those who had symptoms similar to BPPV, but

showed no typical nystagmus in the Dix-Hallpike position, were

grouped as subjective type of BPPV (Tirelli et al., 2001).

2.3. Treatment maneuvers

Posterior canal BPPV was treated by the CRP (Epley, 2001), and

horizontal canal BPPV was treated by the barbecue maneuver

(Lempert and Tiel-Wilck, 1996). Duration of nystagmus less than

60 seconds was diagnosed as canalolithiasis and nystamgus of more

than 60 seconds was cupulolithiasis (Herdman and Tusa, 2007b).

Each patient was treated with either CRP/barbecue maneuver for

canalolithiasis or liberatory maneuver for cupulolithiasis on the

symptomatic side. For those who had simultaneous posterior and

horizontal canal BPPV (two-canal involvement) of the same ear,

PC BPPV was treated first, followed by the barbecue maneuver

48 hours later. For subjective-type BPPV, CRP was performed on

the symptomatic side. No pre-medication or mastoid vibration

was given in our treatment procedures. On their following

visits 3–7 days later, Hallpike examination was performed again.

Treatments were repeated for those who had persistent or recurrent

signs. Brandt-Daroff redistribution exercise was applied for those

who experienced milder or residual complaints of vertigo. Home

program instructions were dispensed as necessary.

2.4. Introduction of canalith repositioning procedure and barbecue

maneuver

The procedure for CRP is as follows: 1. Patient begins in the long-

leg sitting position. 2. The head is rotated 45° towards the affected

side, then lowered down to the supine position, with neck extended

15–20° to the edge of the examination table. 3. Turn head away from

the affected side and bring the other ear down. 4. Lying on the unaf-

fected side of the body, the head is then turned to the ground so that

the patient’s nose is pointing to the ground. 5. Return to the upright

position. Positions 2 to 4 should be held for one minute or until the

nystagmus or vertigo subsides (Figure 1). The Barbecue maneuver:

1. Patient begin in the supine position. 2. Conduct three consecutive

90° head turns toward the unaffected side. 3. End in the starting

position. 4. Each turn was held until the symptom or nystagmus

subsided before proceeding to the next turn. 5. The entire maneuver

was repeated until no symptoms could be elicited (Figure 2).

Fig. 1. Canalith repositioning procedure. (a) Rotate head 45° towards the affected

side, then lower down to supine position, with neck extended 15°-20° to the edge

of the examination table. (b) Turn head away from the affected side and bring the

other ear down. (c) Lie on the unaffected side of the body, and then turn head to

the ground. (d) Back to the upright position.

Fig. 2. The barbeque maneuver (a) Patient in supine position. (b)–(d) Three

consecutive 90° head turns toward the unaffected side. (e) End in starting position.

S52 C-L. Kao et al. / Archives of Gerontology and Geriatrics 49 (2009) S50–S54

2.5. Definition for recurrence

Recurrence of BPPV was defined as recurrent symptoms and signs

of vertigo with positive results in the Dix-Hallpike test after at least

one month of symptom free status.

2.6. Impacts on daily activities

Patients were asked to rate their daily activities limited due

to symptoms caused by BPPV in three perspectives, i.e. work,

household and social activities, ranging from 0 (none) to 10 (most)

on their first visits.

2.7. Statistical analysis

Data was analysed by SPSS 16.0. The Chi-Square test was applied

to analyse the differences of recurrence rate between those aged

above and below 65. The Mann–Whitney U test was used to

evaluate whether there were gender or age differences in the

average duration of first BPPV recurrence. For comparison of the

functional limitation of daily activities between the two age groups,

independent t-test was used.

3. Results

3.1. Demographic data for BPPV patients

Two hundred and eighteen patients were included in this study

(mean age 68.1±14.4 years old, range 24–91 year-old). Past medical

history revealed 45 patients (20.83%) had head trauma and five

(2.35%) had Meniere’s disease. Among the 218 patients diagnosed as

BPPV, 74 were male and 144 were female (1:1.95). One hundred and

seventy-one patients were diagnosed as posterior canal BPPV, in

whom 99 patients had right-side involvement, and 72 patients had

left-side involvement. Eight patients were diagnosed as horizontal

BPPV, seven patients had left-side involvement, and one had right-

side involvement. There were nine patients with subjective-type of

BPPV. Twenty-eight patients had bilateral posterior canal BPPV and

two had two-canal involvement. The demographic data of different

canal involvements is shown in Table 1. The age distribution, in

decades, of the BPPV patients is shown in Figure 3. BPPV was most

prevalent in the 71–80 year age group.

Table 1

Demographic data for different canals of BPPVa

Involved semi-circular canal Total Males Females Age

(years)

Right posterior canal 99 (45.4) 36 (36.4) 63 (63.6) 66.9±14.9

Left posterior canal 72 (33.0) 25 (34.7) 47 (65.3) 68.3±13.6

Right horizontal canal 1 (0.5) 0 (0) 1 (100) 75.0

Left horizontal canal 7 (3.2) 1 (14.3) 6 (85.7) 66.0±18.1

Bilateral posterior canal 28 (12.8) 8 (28.6) 20 (71.4) 72.2±13.7

Two-canal involvement 2 (0.9) 1 (50) 1 (50) 64.0±26.9

Subjective type BPPV 9 (4.1) 3 (33.3) 6 (66.7) 68.1±16.0

Total 218 74.0 (33.9) 144 (66.1) 68.1±14.4

a Values are n (%) or mean±SD.

3.2. Number of treatments required for complete remission of BPPV

Among the 218 BPPV patients, 176 (80.7%) were successfully treated

by a single treatment. Thirty-four (15.6%) patients needed two

treatments, and six patients needed three treatment sessions to

gain relief. The numbers of treatment performed to cure BPPV is

shown in Table 2.

15

15

20

40

60

80

100

25

Ages

Pa

tie

nt

nu

mb

ers

35 45 55 65 75 85 95

Fig. 3. Age distribution of BPPV shown in decades. The incidence of BPPV rises as

the age increases. The incidence peaks in 71–80 year-old population

Table 2

Number of treatments performed in BPPV patients

Number of patients (%) Number of treatments performed after diagnosis

2 (0.9) 0

176 (80.7) 1

34 (15.6) 2

6 (2.8) 3

3.3. Number of treatments, recurrence, and recurrence duration

between age groups

In the young age group, 57 (80.3%) needed one treatment, and 14

(19.7%) patients needed two to relieve symptoms. In the senior age

groups, 119 (81.0%) of patients were treated by a single treatment,

20 (13.6%) of patients needed two treatments, and six (4.1%)

patients needed three treatments. Forty-one patients suffered from

recurrence of BPPV one month after successful treatment. There

were nine patients in the young age group and 32 in the senior

group having recurrence (p =0.07). In the senior age group, mean

duration for recurrence was 6.8±5.3 months, with 3.1±2.7 months

in the young age group (p =0.03). The number of treatments,

distribution and percentage of the BPPV recurrence, and the average

recurrence duration in different age groups is shown in Table 3.

Table 3

The number of treatments, distribution and percentage of the BPPV recurrencies,

and average recurrence duration in different age groupsa

Age < 65 Age ≥ 65 p

Number (%) of patients 71 (32.57) 147 (67.43)

Number of treatments

0 0 (0) 2 (1.4)

1 57 (80.3) 119 (81.0)

2 14 (19.7) 20 (13.6)

3 0 (0) 6 (4.1)

Recurrence rate 9 (12.7) 32 (21.8) 0.07

Recurrence duration

(months)

3.1±2.7 6.8±5.3 0.03*

a Values are n (%), or mean±SD.

*Significant difference between groups (p < 0.05).

C-L. Kao et al. / Archives of Gerontology and Geriatrics 49 (2009) S50–S54 S53

10

8

6

4

2

0

work_VAS household_VAS social_VAS

Daily activities limitation items

Va

lue

age <65

age ≥65

Fig. 4. Impacts on daily activities. For work-related activity limitations: 5.2±3.3 in

the young and 4.1±3.2 in the senior age groups. *Indicates significant difference

between two groups, p < 0.05. For household activity limitations: 5.4±2.5 in the

young and 5.7±2.7 in the senior age groups (p = 0.51). Social activity limitations:

5.6±3.3 in the young and 5.8±2.9 in the senior age groups (p = 0.81).

3.4. Impacts on daily activities

In young and senior age groups, no statistical difference was

found between the subjective feeling of poor balance (p = 0.63), fall

(p = 0.27) and trouble with walking (p = 0.20). The rating of work-

related activity limitation was 5.2±3.3 in the young and 4.1±3.2

in senior age groups (p = 0.03). The rating for household activity

limitation was 5.4±2.5 in the young and 5.7±2.7 in the senior age

groups (p = 0.51). Social activity limitation was 5.6±3.3 in the young

and 5.8±2.9 in the senior age groups (p = 0.81) (Figure 4).

4. Discussion

Our results are in accordance with previous reports (Lynn et al.,

1995; Angeli et al., 2003; Yimtae et al., 2003; Steenerson et al.,

2005), which showed a higher disposition in females of advanced

age, with posterior canal involvement predominating. The incidence

of PC BPPV varies from 76% to 90.2% (Korres et al., 2002; Prokopakis

et al., 2005; Herdman and Tusa, 2007a). It has been proposed that

the incidence of PC BPPV is highest in all canals because PC is

the most gravity-dependent semicircular canal (Korres et al., 2002).

Women are 2.3 times more likely to acquire idiopathic BPPV than

men (1.95 fold in our study) (Katsarkas, 1999). It has been reported

that the age of onset is most commonly seen between 50 and 70

years of age (Mizukoshi et al., 1988; Oas, 2001). According to our

observation, the incidence peaked in the 71–80-year-old age group,

which was older than that reported in the literature. The reason for

this may be due for the fact that our hospital provides services for

both veterans and the civilians, with a high proportion of veterans

visiting the hospital. They are generally older and exclusively male.

This may affect our results for the age distribution and for the male

to female ratio of BPPV occurrence.

Our treatment yielded an 80.7% of success rate after a single

treatment. The treatment efficacy reached 90.8% in PC BPPV (data

not shown). The successful rate of the repositioning maneuver

for posterior canal BPPV ranged from 30% to 100% in one meta-

analysis report (Parnes et al., 2003). Our result was similar to

that of Wolf’s study, which included 102 patients with a 93%

success rate (Wolf et al., 1999). It has been documented that the

secondary causes of BPPV include head trauma, viral labyrninthitis,

Meniere’s disease, migraines and inner ear surgery (Parnes et al.,

2003). In our study, 20.83% of the patients had head trauma

and 2.35% had Meniere’s disease, compared with the 7–17% of

head trauma and 5% Meniere’s reported in the literature (Parnes

et al., 2003). Our incidence of BPPV secondary to other otological

conditions was different because patients’ self-reported past history

might not be accurate. Apart from this, our data did not show

that patients with Meniere’s disease required more treatment

maneuvers, which contradicts with reports that BPPV coinciding

with other vestibular dysfunctions requires more treatment cycles

for a complete symptomatic resolution (Pollak et al., 2002).

Therefore, the value of additional diagnostic tests in the evaluation

of BPPV remains questionable.

Another important issue about BPPV is the recurrence rate.

Our data yielded 18.8% of recurrence rate, which was close to

Furman’s and Prokopakis’ findings (a yearly 15% and 12% recurrence

respectively) (Furman and Cass, 1999; Prokopakis et al., 2005).

Whether right or left side PC BPPV is more prone to recur lacks

a definitive conclusion in previous studies. Our right and left PC

BPPV had approximately the same recurrence rate (16.2% and 16.7%,

respectively), and the bilateral PC BPPV group had the highest

recurrence rate among all canals (35.7%). We found the recurrence

rate in our senior age group was 1.7 times higher than the younger

age group (p =0.07). This finding supports Prokopakis’s conclusion

that age greater than 70 years was the most-identifiable reason

for recurrence, rather than head trauma or vestibular neuropathy

(Prokopakis et al., 2005). The symptom-free duration before BPPV

recurrence was nearly 2.2 times longer in the senior age group

(p =0.03). The reason for this was never proposed in previous

literature, but three possible explanations could be given for this

seemingly contradictory finding. (1) The posterior semicircular

canal is the most commonly involved canal in BPPV. In order to

provoke the symptoms of vertigo, the density and volume of free-

floating clots in the semicircular canals are important factors. It

is possible that older people become less sensitive to the sensory

impulses produced by the free-floating particles and thus BPPV

becomes subclinical. (2) The neck motion in vertical plane in

older people is generally less abrupt and vigorous. Therefore, the

chance for older people to be in triggering positions of PC BPPV

is decreased. (3) Older people are less active, and HC BPPV can be

self-treated when lying on the asymptomatic side.

Previous literature has already documented that BPPV has a

significant impact on the health-related quality of life in elderly

patients (Gamiz and Lopez-Escamez, 2004). In our observation, the

young population perceived significantly more limitations on work-

related functional activities (p = 0.03). The impact on household

and social activities was similar in both age groups. The physical

limitations of BPPV itself can be debilitating. Both young and old

populations had poor balance and trouble with walking, and more

than 20% of them had falls. Whether our patients improved in ADL

functions after treatment were not evaluated in this study.

5. Conclusion

Our study has demonstrated a higher occurrence and recurrence

rate of BPPV in those of senior age. Life quality could be affected by

the violent sensation of vertigo and more than 80% of BPPV patients

could be cured by a single treatment. Although the nature of this

disease is benign, the sequelae of BPPV may be devastating if left

untreated. Early diagnosis and prompt management are mandatory

to facilitate recovery and reduce medical expense.

Conflict of interest statement

The authors have no conflicts of interest to report.

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