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Physio Matters

Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) accounts for 32% of all causes of vertigo (dizziness). It can occur in adults of all ages, but often affects individuals over the age of 60, and is more common in women than in men.

Symptoms of vertigo including feeling that your surroundings are moving or spinning, as well as nausea, vomiting, or motion sickness. Symptoms typically occur when there is a change to the position or orientation of the head, especially when bending forward, looking up, lying down, or rolling over in bed. BPPV also affects balance and the person may become unsteady on their feet. In addition, abnormal eye movements (nystagmus) usually accompany the symptoms of BPPV. These eye movements typically beat rhythmically in a vertical or horizontal direction.

In approximately 35% of cases BPPV occurs without a known cause, but may also be associated with head trauma (15%), and inner ear infections (15%). BPPV has also been associated with hypertension, hyperlipidemia, migraines, and stroke.

The physiological mechanism of BPPV involves the vestibular labyrinth of the ear, which contain 3 looped structures called the semicircular canals. These canals are responsible for monitoring the rotation of the head. When calcium carbonate crystals (otoconia) become dislodged from one of the inner ear organs (utricle) they can migrate into the semicircular canals. When the head changes position, so do the crystals in the canals, which causes an unwanted flow of fluid that continues even after the head has stopped moving. This causes the body to falsely interpret that the surroundings are spinning. The direction of the nystagmus (vertical vs. horizontal) can help clinicians determine which semicircular canals are affected.

It is estimated that 50% of BPPV cases resolve spontaneously. The average duration of BPPV is 2 weeks and recurrent episodes occur in 40% of patients. Treatment of BPPV may involve specific physiotherapy maneuvers and an exercise program designed to reposition the crystals out of the semicircular canals. It is then thought that the crystals are reabsorbed by the body. The results of these maneuvers can vary, with some patients experiencing immediate relief, while others may require follow up maneuvering.

If you are experiencing vertigo or dizziness please consult with your primary care provider to determine a diagnosis for your condition. There are several other medical conditions that may cause dizziness or vertigo so it is important to seek medical attention as soon as possible. If you are diagnosed with BPPV your physiotherapist can help guide you through a series of maneuvers that may help to ease your symptoms.


Carpal tunnel syndrome

Carpal tunnel syndrome is a condition in which the median nerve becomes irritated or compressed in the carpal tunnel of the wrist.  The median nerve supplies the thumb, index finger, middle finger, and radial half of the ring finger (side closest to the thumb).  The carpal tunnel houses 9 flexor tendons and the median nerve at the base of the palm.  Carpal (wrist) bones surround the tunnel forming an arch.  The median nerve can be compressed by decreasing the size of the tunnel or increasing the size of the tendons (swelling within the tunnel).  Flexing the wrist to 90 degrees will also decrease the size of the tunnel. 

Symptoms such as pain and altered sensation (numbness, tingling) occur in the thumb, index, middle, and radial half of the ring finger, and often result in weakness in the thenar muscles (base of the thumb).  Numbness often occurs at night as it is thought that wrists may become flexed during sleep.  Loss of grip strength and generalized pain of the wrist and hand are also characteristic of this condition. 

Carpal tunnel syndrome is often idiopathic (due to an unknown cause).  However, there are some medical conditions that can lead to its onset such as: Obesity, hypothyroidism, arthritis, previous fractures of the wrist, diabetes, and pregnancy.  In addition, work related risk factors, such as excessive force, lack of ergonomic positioning, vibrational forces, and repetitive movements have been shown to be associated with the onset of this condition. 

The diagnosis of carpal tunnel involves a combination of the patient's history and description of symptoms, clinical findings, and electrodiagnostic testing.  Patients often report altered sensation in the median nerve distribution, symptoms that occur while sleeping, and weakness in the thumb muscles.  Clinically, tests such as the Phalen's maneuver and Tinel's sign can be performed in a physical assessment by a health care provider.  Phalen's maneuver involves flexing the wrist for at least 60 seconds.  A positive test is indicated when numbness and/or pain is felt in the median nerve distribution within 60 seconds.  Tinel's sign is performed by lightly tapping over the carpal tunnel.  A positive result is indicated if the tapping causes a tingling sensation in the median nerve distribution.  Electrodiagnostic testing may include nerve conduction tests that can determine median nerve abnormalities. 

Prevention of carpal tunnel syndrome involves avoiding repetitive movements, adopting more ergonomic positions and/or the use of ergonomic equipment.  Treatment may include bracing/splinting of the wrist, physiotherapy, or surgery.  Physiotherapy treatments may include ultrasound, exercise and stretching prescription, and/or manual mobilization by your physiotherapist.  Please check with your primary health care provider to determine a diagnosis for your wrist pain and the most appropriate treatment plan for your condition. 

The muscles of the rotator cuff

The rotator cuff is composed of 4 muscles of the shoulder. Each muscle connects from the scapula (shoulder blade) to the greater and lesser tubercle (rounded prominences of bone where muscles attach) of the humerus (upper arm bone), forming a "cuff".

The function of the rotator cuff is to allow for motion of the shoulder joint and to provide stability. The four muscles of the rotator cuff are outlined below, including where each muscle originates and then attaches, the movement each produces, and the nerves that supply (innervate) each muscle:


Supraspinatus Muscle

This muscle originates on the supraspinous fossa (small groove) of the scapula and attaches to the superior (top) and middle facets (small, smooth area of bone) of the greater tubercle of the humerus. Its function is to abduct the arm (raises the arm out to the side). It is innervated by the suprascapular nerve.




Infraspinatus Muscle

This muscle originates on the infraspinous fossa of the scapula and attaches to the posterior (back) facet of the greater tubercle of the humerus. Its function is to externally rotate the arm. It is innervated by the suprascapular nerve.





Teres Minor Muscle

This muscle originates on the middle half of the lateral (outside) border of the scapula and the attaches to the inferior (below) facet of the greater tubercle of the humerus. This muscle also externally rotates the arm. It is innervated by the axillary nerve.




Subscapularis Muscle

This muscle originates on the subscapular fossa of the scapula and attaches to the lesser tubercle of the humerus. Its function is to internally rotate the arm and it is innervated by the upper and lower subscapular nerve.


These four muscles can be remember by the acronym "SITS".


Bursitis 101

What is Bursitis?

A bursa is a sac like structure filled with fluid that is found in several joints in the body. The bursa acts as a cushion between bones, tendons, and muscles within a joint. There are approximately 160 bursae within the human body. Each bursa is lined with synovial cells that produce a lubricant to help reduce friction in the joints, allowing ease of movement. When a bursa becomes inflamed, pain is experienced within a joint.


What causes bursitis?

Bursitis is most often caused by overuse injuries, in which repetitive motions place stress on the joints. Examples of activities that require repetitive motions include: running or walking long distances, shoveling, painting, scrubbing, gardening, golfing, and throwing. In addition, inflammation from conditions including rheumatoid arthritis, gout, or infections can predispose someone to bursitis. Finally, people with poor conditioning that are required to perform activities for long periods of time (such as walking long distances) are more susceptible to developing bursitis.


What joints does bursitis affect?

Bursitis can occur in any joint with a bursa. The elbow, shoulder, hip, and knee are common sites for bursitis.


What are the symptoms of bursitis?

Localized pain of the joint is the most common symptom. Pain may increase over time or may suddenly occur, and will typically increase with movement. Swelling and tenderness may also be present as well as loss of range of motion.


How is bursitis treated?

Often rest, ice, compression, and elevation (RICE principle) can be used to treat bursitis. In my opinion, ice is the single most important thing you can do on your own to reduce the inflammation of the bursa. Ice can be applied for 15 minutes every couple of hours. Ensure that there is a towel between the ice and your skin. I often tell patients to use frozen peas or corn that mold well to the affected area. Letting the joint rest is also very important. Ensure that your pain has decreased prior to returning to an activity that may have contributed to the bursitis. For example, if walking long distances may have contributed to the bursitis then I would suggest waiting until the pain has decreased substantially before attempting to return to your walking program. In addition, starting out slowly and gradually increasing the amount of time spent walking may help to prevent the return of your symptoms. Finally, compressing and elevating the joint may also help to reduce the swelling and inflammation.

Physiotherapy modalities, such as pulsed ultrasound, can also help to decrease inflammation within the joint. Your doctor may also prescribe specific medications such as an anti-inflammatory to help reduce the swelling. Please consult with your health care provider to determine an appropriate treatment plan for your bursitis.

Read more Physio Matters articles


About the Author

Kristi Scott, B.Sc., M.Sc.P.T., CAFCI

Kristi is a registered physiotherapist. She joined her mother, Shirley Andrusiak, at Guisachan Physiotherapy after graduating from the Masters of Science in Physical Therapy Program at the University of Alberta in 2010. She also holds an Undergraduate Bachelor of Science Degree from the University of Victoria. Since graduating Kristi has completed numerous continuing education courses including manual therapy, vertigo, and golf related rehabilitation.  She has also completed her training with the Acupuncture Foundation of Canada Institute, and is certified to perform acupuncture techniques, holding a designation of CAFCI.

Kristi brings an energetic, exercise based approach to her practice. She focuses on client centered care, education, exercise prescription, and manual therapy techniques.  She has a special interest in hockey related injuries and volunteers for the Kelowna Chiefs Junior Hockey Club.

You can contact Kristi by email at [email protected]



The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet presents its columns "as is" and does not warrant the contents.

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