A New Maneuver for Vertigo Relief in Patients with APO-HSC-BPPV: The Square Wave Technique Offers Hope for Those with Neck Restrictions
Vertigo, that unsettling sensation of spinning or dizziness, can dramatically disrupt daily life, impacting balance, coordination, and overall well-being. Benign paroxysmal positional vertigo (BPPV), a frequent culprit behind vertigo episodes, arises when tiny calcium crystals, normally embedded within the inner ear's balance organs, become dislodged. These errant crystals, adrift in the inner ear fluid, send confusing signals to the brain, triggering the illusion of movement.
While BPPV is often treatable with maneuvers that reposition the dislodged crystals, these techniques commonly involve significant neck movement. This poses a significant challenge for individuals with neck restrictions due to arthritis, injury, or other conditions.
A recent study (Yacovino et al., 2021) published in the Journal of Vestibular Research sheds light on a potential solution: the "square wave maneuver." This innovative approach targets a specific subtype of BPPV, the apogeotropic variant of horizontal canal BPPV (HC BPPV-AG), notorious for its resistance to standard treatments. This variant is particularly prevalent in individuals with neck mobility issues.
Decoding the Square Wave Maneuver
The square wave maneuver involves a series of carefully controlled head and body rotations while the patient is lying down. It's designed to address a specific challenge: when the crystals aren't just loose but stuck to a sensitive part of the inner ear called the cupula.
The Stuck Crystal Problem: Imagine tiny grains of sand clinging to a delicate weather vane. Even a slight breeze (like gravity in your inner ear) can't dislodge it, causing the vane to spin erratically. This is similar to what happens in HC BPPV-AG.
Enter the Square Wave: The maneuver uses a combination of gravity and quick movements to shake the crystal loose. Here's how it works:
The patient lies down, and their head is turned to the affected ear side, triggering the vertigo and rapid eye movements (nystagmus).
At the peak of these symptoms (80% to 100%), the head and body swiftly rotated 180 degrees to the opposite side. This sudden shift creates a force that tries to pull the crystal off the cupula, like a strong gust of wind on a weather vane.
This back-and-forth motion is repeated rhythmically, increasing pressure until the crystal is dislodged. This should be done in around 5.0 seconds to the right and left, like a gently rocking motion to assist the crystals to come loose.
What to Look For:
There are two possible scenarios:
SHORT-ARM (orange debris): If the debris is on the short-arm side of the cupula, you should see a brief, intense nystagmus (sign) and vertigo (symptoms) that disappears as it causes an ampullopetal deflection of the cupula as it passes into the utricle.
LONG-ARM (blue debris): If the debris is on the long arm side of the cupula, the successful maneuver will cause a reversal of nystagmus (sign) and less vertigo (symptoms) from the original apogeotropic to geotropic as you are getting inhibition of the canal due to ampullofugal flow.
Keep Trying: The crystal is still stuck if the nystagmus doesn't change. The therapist will continue the square wave motion until it's dislodged, even up to 10 repetitions.
Promising Study Results
The study examined 15 patients with HC BPPV-AG and neck restrictions who hadn't responded to other treatments. Impressively, 14 out of 15 saw their vertigo completely resolve after just one session of the square wave maneuver. The maneuver was well-tolerated, with no reported side effects.
Advantages of the Square Wave Maneuver
Neck-Friendly: Perfect for those who can't do maneuvers requiring lots of neck movement.
No Guesswork: This can be used even when it's unclear which ear is affected.
Comfortable: Patients generally find it easy to tolerate.
The Road Ahead
More research is needed, but the square wave maneuver shows real promise for treating a particularly stubborn type of vertigo, especially in people with neck problems. It's a potential game-changer, offering relief and improved quality of life.
Remember: If you have persistent vertigo, see a doctor for diagnosis and treatment.
Disclaimer: This article is for informational purposes only and should not be considered a substitute for professional medical advice. Always consult a qualified healthcare provider regarding any health concerns or before making any decisions related to your health or treatment.
References
 Yacovino DA, Zanotti E, Roman K, Hain TC. Square wave maneuver for an apogeotropic variant of horizontal canal benign paroxysmal positional vertigo in neck restricted patients. J Otol. 2021 Apr;16(2):65-70. doi: 10.1016/j.joto.2020.10.003. Epub 2020 Nov 5. PMID: 33777117; PMCID: PMC7985006.