How does BPPV treatment work?

Many people are curious as to how BPPV treatment works.

The goal of BPPV treatment is like winning a biological pinball game.

In handheld pinball games, the player has to tip the game side to side and also tip it in certain other directions to win. The goal is coaxing the little ball that’s inside the pinball game to roll in a certain way along a track, wherever you want to send it.

That is very similar to what we have to do with the person’s head for BPPV treatment.

The “Epley Maneuver” was the first of this type of BPPV treatment invented in 1992.

Since then, a wide variety of BPPV maneuvers have been developed by researchers worldwide.

A difference between BPPV treatment and my pinball game analogy is that we cannot see the pinball track inside the skull bones when we treat BPPV crystals.

Also, the person’s head is attached to their body, so we have to move their body around during the treatment as well.

The goal with BPPV treatment is to reposition the crystals that have become dislodged inside the inner ear semi-circular canals.

The vestibular system is actually embedded in the petrous portion of the temporal bone or deep inside the cheekbone. If you place your finger on the bone right in front of your ear hole, that’s basically where the vestibular system is located, deeper within the skull.

The vestibular system contains sensory organs to help us balance, on both the left side and on the right side of the skull in the respective inner ears. We also have designated vestibular pathways in our brain to transmit the information.

As a vestibular expert, during BPPV treatment, my job is to figure out where the BPPV crystals have traveled.

There are three semi-circular canals in the left inner ear and three semi-circular canals in the right inner ear, where the BPPV crystals may have traveled.

These dislodged crystals can be found in both the left side AND the right side, in a maximum of up to three semi-circular canals on each side.

There are a total of about 10-12 locations within the 6 semi-circular canals where BPPV crystals can travel. They all must be checked.

It is possible that there is more than one BPPV crystal dislodged, like a debris or sediment of crystals, and they often travel in clusters. That is the reason BPPV can sometimes take a few treatments to clear up.

BPPV treatment requires a very precise knowledge of the anatomy of those canals inside the vestibular system.

We can’t move the crystals with our fingers. They are too small and hidden from view, so the healthcare provider has to memorize their location and pathways.

The whole vestibular system is a tiny labyrinth.

We have to actually move the person’s head in a certain predictable way to essentially win the pinball game in their vestibular labyrinth. At each stopping point during BPPV treatment, we are waiting for gravity to pull the crystals along in the desired direction, much like a pinball game.

This type of BPPV treatment can resolve the vertigo from BPPV.

That is why BPPV treatment is commonly called “crystal repositioning maneuvers” or CRM.

Technically, “CRM” stands for canalith repositioning maneuver, with the word “canalith” meaning “ear stones.”

If we can successfully reposition the crystals with BPPV treatment techniques, we can help people with their vertigo and get their life back!


This blog is provided for informational and educational purposes only. The content and any comments by Dr. Kim Bell, DPT are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of any case mentioned in this post represent a typical patient that Dr. Bell might see and do not describe the circumstances of a specific individual.

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