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Patient Information | Frequently Asked Questions: Benign Paroxysmal Positional Vertigo (BPPV)

Q: What is BPPV?

A: Benign Paroxysmal Positional Vertigo (BPPV) is the most common inner ear problem and cause of vertigo, or false sense of spinning.

BPPV is a specific diagnosis and each word describes the condition:
Benign: it is not life-threatening, even though the symptoms can be very intense and upsetting
Paroxysmal (par-ek-siz-muhl): it comes in sudden, short spells
Positional: certain head positions or movements can trigger a spell
Vertigo: feeling like you are spinning or the world around you is spinning1

Q: What causes BPPV?

A: There are crystals of calcium carbonate that are a normal part of our inner ear and help us with our balance and body motion. These tiny rocklike crystals or “otoconia” (oh-toe-cone-ee-uh) are settled in the center “pouch” of the inner ear. BPPV is caused by the crystals becoming “unglued” from their normal place. They begin to float around and/or get stuck on sensors in the wrong part or wrong canal of the inner ear. The most intense part of your BPPV symptoms have to do with how long it takes the crystals or sensor to settle after you move or change your head or body position. As the crystals move and settle, your brain is getting powerful (false) messages telling you that you are violently spinning when all you may have done is laid down or rolled over in bed.

Q: What are the common symptoms and how can BPPV affect me?

A: Everyone will experience BPPV differently, but there are common symptoms. The most common symptoms are distinct triggered spells of vertigo or spinning sensations. You may experience nausea (sometimes vomiting) and/or a severe sense of disorientation in space. You may also feel unstable or like you are losing your balance. These symptoms will be intense for seconds to minutes. You can have lasting feelings of dizziness and instability, but at a lesser level, once the episode has passed. In some people, especially seniors, BPPV can appear as an isolated sense of instability brought on by position change like sitting up, looking up, bending over and reaching. BPPV does not cause constant severe dizziness and is usually triggered by movement. BPPV does not affect your hearing or cause you to faint. The natural course of BPPV is to become less severe over time. People will often report that their very first BPPV spinning episode was the worst and the following episodes were not as bad.

Q: How common is BPPV?

A: BPPV is very common. It is more common in older people. Many of us will experience it at some time in our lives.

Q: What caused my BPPV?

A: Most cases of BPPV happen for no reason. It can sometimes be associated with trauma, migraine, other inner ear problems, diabetes, osteoporosis, and lying in bed for long periods of time (preferred sleep side, surgical procedures, illness).

Q: How is BPPV diagnosed?

A: Normal medical imaging, such as scans and X-rays, or medical laboratory testing cannot confirm BPPV. Your health care provider or examiner will complete simple bedside testing to help to confirm your diagnosis. The bedside testing requires the examiner to move your head into a position that makes the crystals move and will make you dizzy. The testing may include hanging your head a little off the edge of the bed or rolling your head left and right while lying in bed. The examiner will be watching you for a certain eye movement to confirm your diagnosis. The most common tests are called the Dix-Hallpike test or supine roll test.

Q: Can BPPV be treated?

A: Yes. Although medications are not used other than for relief of immediate distress, such as nausea, most BPPV cases can be corrected with bedside repositioning exercises that usually take only a few minutes to complete. They have high success rates (around 80%) although sometimes the treatment needs to be repeated a few times. These maneuvers are designed to guide the crystals back to their original location in your inner ear. They can be done at the same time the bedside testing for diagnosis is being performed.

You might be sent to a health professional (medical provider, audiologist or therapist) who can perform these maneuvers, especially if you have any of the following:

  • severe disabling symptoms
  • you are a senior with history of past falls or fear of falling
  • you have difficulty moving around (such as joint stiffness especially in your neck and back and/or weakness).

You can also be taught to perform these maneuvers by yourself with supervision which is called “self-repositioning.”

Q: Is there any down side to BPPV repositioning treatments?

A: During the actual BPPV treatment there can be some brief distress from vertigo, nausea, and feelings of disorientation. Following the treatment, some people report their symptoms start to clear right away. Many times, others report that they have continuing motion sickness-type symptoms and mild instability. These symptoms can take a few hours or a few days to go away.

Q: Can BPPV go away on its own?

A: There is evidence that if BPPV is left untreated, it can go away within weeks. However, remember that while the crystal is out of place, in addition to feeling sick and sensitive to motion, your unsteadiness can increase your risk for falling. You will need to take precautions not to fall. You are at a higher risk for injury if you are a senior or have another balance issue. Seniors are encouraged to seek professional help quickly to resolve symptoms.

Q: How do I know my BPPV has gone away?

A: The strong spinning sensations that have been triggered by position changes should be greatly reduced if not completely gone.

Q: How long will it take before I feel better?

A: You can still feel a little bit sensitive to movement even after successful treatments for BPPV. You can also feel unsteady at times. These mild symptoms can take a few days to a few weeks to slowly go away. You should follow up with your medical provider or physical therapist if your symptoms of dizziness or instability do not get better in a few days to a couple of weeks. Seniors with a history of falls or fear of falling may need further exercises or balance therapy to clear BPPV completely.

Q: Is there anything I should or shouldn’t do to help my BPPV?

A: Yes. Your balance will be “off” so you will need to take precautions that you don’t fall. You will feel more sensitive to movement until the BPPV has been successfully treated and healed. After your symptoms are slowly going away, it is important to return to normal activities that you can do safely. Exposure to motion and movement will help to speed your healing.

Q: Can BPPV come back and/or can I prevent it?

A: Unfortunately, BPPV is a condition that can sometimes return. Your risk for BPPV returning can shift from low risk (few experiences in your lifetime) to a higher risk which is often caused by some other factor such as trauma (physical injury), other inner ear or medical conditions, or aging. Medical research has not found any way to stop BPPV from coming back, but it can be treated with a high rate of success.

Q: What happens if I still have symptoms following my initial treatments?

A: There are a number of reasons your initial treatment could have failed.

  1. It is not uncommon to need more than one repositioning session to get the crystals back in their proper place. You may only need a few more treatments.
  2. There are a number of different forms or types of BPPV, which can require special treatment. The self-treatment is designed for the most common form of BPPV. There are a number of other treatments available, which depend on the different types of BPPV.
  3. BPPV can sometimes be in more than one canal and/or side at the same time. This would require multiple treatments to resolve.
  4. If your initial tries at repositioning have failed, mainly if you have only tried self-repositioning, seek a health professional who specializes in BPPV. It can be difficult to complete correct positioning by yourself. A professional may be able to complete better positioning and/or use helpful equipment.
  5. There can be some significant leftover dizziness even after the BPPV crystals have been correctly repositioned. This dizziness may require more time (few days to couple of weeks) or it may be appropriate for a different exercise/movement routine. It is VERY important to follow-up with your healthcare provider if you continue to have symptoms. You may be sent for further testing to confirm your diagnosis and/or discuss further treatment options.


For more information on BPPV, visit: www.entnet.org/BPPVCPG

Vestibular Disorders Association (VEDA):
INFO@vestibular. org
5018 NE 15th Ave., Portland OR 97211
(800) 837-8428

1 Adapted from Woodhouse, S. “Benign Paroxysmal Positional Vertigo (BPPV)”. (n.d., para. 1). Retrieved from https://vestibular.org/understanding-vestibular-disorders/types-vestibular-disorders/benign-paroxysmal-positional-vertigo

SOURCE: Bhattacharyya, NM, Gubbels, SP, Schwartz, SR, et al; Clinical Practice Guideline (Update): Benign Paroxysmal Positional Vertigo. Otolaryngol Head Neck Surg. In press.


The American Academy of Otolaryngology–Head and Neck Surgery (www.entnet.org), one of the oldest medical associations in the nation, represents about 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology–head and neck surgery through education, researach, and lifelong learning. The organization’s vision: “Empowering otolaryngology–head and neck surgeons to deliver the best patient care.”

Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is a problem in the inner ear. It is the most common cause of vertigo, which is a false sensation of spinning or movement.

What causes BPPV?

BPPV occurs when tiny calcium crystals called otoconia come loose from their normal location on the utricle, a sensory organ in the inner ear.

If the crystals become detached, they can flow freely in the fluid-filled spaces of the inner ear, including the semicircular canals (SCC) that sense the rotation of the head. Otoconia will occasionally drift into one of the SCCs, usually the posterior SCC given its orientation relative to gravity at the lowest part of the inner ear.

The otoconia will not cause a problem when located in an SCC until the person’s head changes position, such as when looking up or down, going from lying to seated or lying to seated in bed, or when rolling over in bed. The otoconia move to the lowest part of the canal, which causes the fluid to flow within the SCC, stimulating the balance (eighth cranial) nerve and causing vertigo and jumping eyes (nystagmus).

BPPV Symptoms

People with BPPV can experience a spinning sensation — vertigo — any time there is a change in the position of the head.

The symptoms can be very distressing. People can fall out of bed or lose their balance when they get up from bed and try to walk. If they tilt their head back or forward while walking, they may even fall, risking injury. Vertigo can cause the person to feel quite ill with nausea and vomiting.

While the hallmark of BPPV is vertigo associated with changes in head position, many people with BPPV also feel a mild degree of unsteadiness in between their recurrent attacks of positional vertigo.

The onset of BPPV may be abrupt and frightening. People may think they are seriously ill; for example, they may fear they are having a stroke. A doctor’s diagnosis of BPPV can be reassuring, especially when people understand that help is available to relieve their symptoms.

Without treatment, the usual course of the illness is lessening of symptoms over a period of days to weeks, and sometimes there is spontaneous resolution of the condition. In rare cases, the person’s symptoms can last for years.

What brings on BPPV?

In many people, especially older adults, there is no specific event that causes BPPV to occur, but there are some things that may bring on an attack:

  • Mild to severe head trauma

  • Keeping the head in the same position for a long time, such as in the dentist chair, at the beauty salon or during strict bed rest

  • Bike riding on rough trails

  • High intensity aerobics

  • Other inner ear disease (ischemic, inflammatory, infectious)

BPPV Diagnosis

Diagnosing BPPV involves taking a detailed history of a person’s health. The doctor confirms the diagnosis by observing nystagmus — jerking of the person’s eyes that accompanies the vertigo caused by changing head position. This is accomplished through a diagnostic test called the Dix-Hallpike maneuver.

First, while sitting up, the person’s head is turned about 45 degrees to one side. Next, the patient is quickly laid down backward with the head just over the edge of the examining table. This move can often bring on the vertigo and the doctor can observe to see if the person’s eyes show the jerking pattern of nystagmus. A positive response confirms the diagnosis of BPPV. An MRI or CT scan of the brain is usually unnecessary.

A doctor’s diagnosis of BPPV can be reassuring, especially when the patient understands that help is available to relieve the symptoms. Even without treatment, the usual course of the illness is lessening of symptoms over a period of days to weeks, and sometimes there is spontaneous resolution of the condition.

BPPV Treatment

The Epley Maneuver for BPPV

BPPV with the most common variant (crystals in the posterior SCC) can be treated successfully — with no tests, pills, surgery or special equipment — by using the Epley maneuver.

This simple, effective approach to addressing BPPV involves sequentially turning the head in a way that helps remove the crystals and help them float out of the semicircular canal. Several repositioning maneuvers performed in the same visit may be necessary.

The Epley maneuver and other bedside physical therapy maneuvers and exercise programs can help reposition the crystals from the semicircular canals. Recurrences can occur, and repeat repositioning treatments are often necessary.

After Epley maneuver treatment, the patient may begin walking with caution. He or she should avoid putting the head back, or bending far forward (for example, to tie shoes) for the remainder of the day. Sleeping on the side of the affected ear should be avoided for several days.

If the crystals are in a location other than the posterior semicircular canal, slightly different maneuvers may be used, but they are based on the same principle of moving the stones out of the offending semicircular canal. BPPV of the anterior canal is exceedingly rare, since debris in this canal (located at the top of the inner ear) easily falls out on its own.

Other Treatments for BPPV

Usually no medications are required for BPPV unless the patient has severe nausea or vomiting. If extreme nausea is present, the doctor may prescribe or administer anti-nausea medications, especially if the person would not be able to tolerate repositioning maneuvers otherwise.

Surgery is seldom necessary to treat this condition. In rare cases, the doctor may recommend a surgical procedure to block the posterior semicircular canal to prevent stones from entering and moving within the canal. While the surgical plugging procedure cures the problem, it carries some risk, including hearing loss.

Over the long term, BPPV recurs in about half of people who experience it. For those who experience frequent recurrence, home exercises can help them manage symptoms themselves.

Vertigo – Should You Be Concerned?

Vertigo is an unsettling feeling that the world is spinning around you while you’re standing still. Sometimes accompanied by nausea, this sensation can occur as you turn your head or change body positions, such as when you rise from a prone or seated position. While the discomfort may be intense, it usually resolves momentarily as the brain adapts to changes in the inner ear and restores a sense of balance.

What causes vertigo?

There are two main types of vertigo – peripheral and central – and the causes of each can vary. Peripheral vertigo is relatively common and usually brought on by a disturbance in the inner ear. This can be caused by postural hypotension, which is a quick drop in blood pressure. Other possible causes include a buildup of calcium crystals (benign paroxysmal positional vertigo), a buildup of fluid (Meniere’s disease) or an infection (acute peripheral vestibulopathy) in the inner ear. On the other hand, central vertigo is rarer and can result from a migraine, stroke, multiple sclerosis or a tumor in the cerebellum, which is the region of the brain that controls balance.

What should you do?

As a general rule of thumb, you should seek medical attention if you experience vertigo that is severe, recurrent or long-lasting. In rare cases, vertigo may be associated with a serious medical condition, so you should call 911 or go directly to the nearest emergency room if your sense of imbalance is accompanied by:

  • Shortness of breath
  • Chest pains
  • Facial numbness
  • Sudden changes in speech, vision or hearing
  • Walking difficulties
  • Falling
  • Fever
  • A stiff neck
  • A head injury
  • Seizures
  • Loss of consciousness

If you experience mild vertigo, there are some steps you can take to increase your comfort as your body naturally restores your sense of balance. It’s best to move slowly, especially when standing up. Because dehydration can cause dizziness, it’s important to drink plenty of water and other fluids. Finally, caffeine and tobacco can restrict blood flow and worsen the symptoms of vertigo, so it’s a good idea to avoid (or reduce your consumption of) products that contain these stimulants.

If you have questions about the relationship between cancer and vertigo, you are welcome to talk with the experts in the Neuro-Oncology Program at Moffitt Cancer Center. To request an appointment, call 1-888-663-3488 or complete a new patient registration form online. No referrals are necessary.


When Vertigo Strikes: The Questions I Needed Answered


Feb. 10, 2020

By Kay McCallum

My first time experiencing vertigo was while turning over in bed in the middle of the night.

After securing a death grip on my bed sheets, I remember panicking and thinking, “How can it be so quiet?” Surely a natural disaster is happening! I looked over at my husband, only a few inches away, to see if he was okay — he was sound asleep.

So was that just the most vivid dream I’ve ever had? I’ll just finish turning over and go back to…”WHAT WAS THAT?”

This was no dream. I was experiencing so much motion, and I couldn’t tell if I was moving up, down or round and round. I felt terrified — even though I was clearly safe in my bed.

I realized it only occurred when I moved, but the feeling was so real that I couldn’t stop myself from grabbing the bed frame. It seemed almost disabling to feel like I had no control over my own body. My anxiety was through the roof. I kept thinking, “Can I drive? Can I walk upstairs? How can I live my life feeling like I’m about to fall?”

I don’t think anyone can truly prepare themselves for what vertigo feels like. But, I do think that knowing what I know now may have helped damper some of my initial panic.

If you’re experiencing vertigo for the first time, you may have some of the same questions as I did.

How can I tell if it’s vertigo?

I knew I needed to see a doctor, but I still didn’t really know what was causing my symptoms. I thought it could be a sinus infection that had turned into a really bad ear infection. I figured I’d be fine after a few days of antibiotics.

After explaining my symptoms to my doctor, he mentioned I may have benign paroxysmal positional vertigo (BPPV) — one of the most common types of vertigo.

It turns out that BPPV is pretty easy to diagnose. While lying down and turning your head left and right, they watch your eyeball for rapid eye movements called nystagmus. They can see these right away, and it’s a sign of BPPV. And, sure enough, I had it.

Why does vertigo happen?

My doctor explained that vertigo is a balance disorder that starts in your inner ear. There are some tiny (but very important) bony structures in your inner ear surrounded in fluid that sense gravity and help with balance.

It’s not always clear why it happens, but these structures can break off. If this happens, the loose fragments can produce false signals when they settle in certain parts of your ear. These false signals confuse your brain into thinking you’re moving, when in fact you are still.

Why does vertigo make me so anxious?

Even once you realize that what you’re feeling isn’t actually real, it’s almost impossible to convince your brain of that. One of the most challenging parts about vertigo is the battle you fight with your mind. You’re trying to get your brain to understand that you’re not in any danger — but it’s so hard.

I could be lying in a king-size bed, surrounded by pillows, but I was still terrified to lie down in bed, put my shoes on or even scroll on my phone. That’s how real it all feels.

The good news is that the feeling of intense motion trails off in a week or so — but future episodes remain a possibility. In my case, it returned three weeks later and lasted another four days.

How will vertigo affect my daily life?

Even after a vertigo episode ends, there may be residual effects on your balance. During each of my BPPV episodes, which lasted between four to seven days, the periods of intense motion lasted just five or six seconds each. But, my overall balance was impaired well past the episode. It was several months, in fact, before I felt confident with everyday tasks like walking downstairs, putting my shoes on, picking up an object from the floor, moving my head while walking…and the list goes on.

To be fair, I’ve never been the most coordinated person. So to help me feel more confident about my balance, I saw a physical therapist who taught me some techniques for improving my overall balance.

How is vertigo treated?

There are a few ways to reduce vertigo symptoms, but what helped me the most was canalith repositioning treatment, or CRT.

The canalith maneuver works much like one of those small water-filled toys that you manipulate to try to make a tiny metal ball move through a plastic hoop. Your inner ear has loop structures filled with fluid, and if you move your head a certain way you can encourage the loose fragments to move through the loop to a place where they no longer cause disturbance.

The maneuver isn’t actually difficult, but it’s anxiety-inducing if you have vertigo. It requires the same head movements and body motions that trigger the feeling of chaotic motion, so I found it hard to concentrate on performing the maneuver correctly. To make matters worse, if you don’t get the moves exactly right the loose structures will remain in an area where they continue to cause disturbance — so nothing is gained. Also, there is another type of vertigo where the maneuver is not recommended, so I wanted to be sure CRT was safe for me.

The answer for me was physical therapy. With a therapist, I felt confident that I would not fall and could focus on performing the movements correctly.

Will my vertigo ever come back?

My vertigo went away a few days after the canalith repositioning maneuver, and it hasn’t come back since. My doctor couldn’t really tell me what caused my BPPV, but did mention that BPPV is more common as you get older — and also more common in women.

I don’t know if I’ll ever get BPPV again. While I hope I don’t, I know I’ll be more prepared than I was the first time.

Vertigo | Ministry of Health NZ


If you have vertigo, you may feel as though you are spinning, falling or tumbling in space, or standing still while your surroundings are moving.

Vertigo often begins suddenly and may vary in intensity. It may be constant or it may come and go.

Vertigo or giddiness is often mistaken for light-headedness or dizziness. Light-headedness is a feeling that you are going to lose consciousness or faint (pass out). This feeling isn’t caused by an inner ear problem but is due to a lack of oxygen flowing to the brain.

If you have vertigo it’s normal to feel out of control and frightened – but in most cases, the causes of vertigo aren’t a serious health threat.

If you have vertigo you may also have these symptoms:

  • nausea and vomiting
  • tinnitus or ringing in your ears
  • decreased hearing
  • ear pain.

Causes of vertigo

Some people with vertigo have a disorder of the nerve that ends in the part of the inner ear called the labyrinth or balance organ. There can also be problems with the balance organ itself such as:

  • build-up of fluid
  • infection
  • tumours.

One common cause is called benign positional vertigo (BPV). This is usually brief, and related either to infection or a loose object or matter moving inside the balance organ. The vertigo is worsened by changes in head position – such as standing from lying, or rolling over in bed.

Your doctor may show you some exercises that are designed to dislodge the loose object or matter. Antihistamine and anti-nausea medications may also help to relieve your symptoms.

Many cases of vertigo will resolve on their own.

Problems outside the inner ear can also cause vertigo. These include:

  • medications
  • injury to the brain
  • migraine, with or without headache.

When to see your doctor

Because there are many causes of vertigo in addition to inner ear problems, it’s important to find out what might be the cause in your case.

Vertigo may go away or reduce when the underlying cause is treated. In some cases surgical procedures may be a part of the treatment.

Call Healthline 0800 611 116 if you are unsure what you should do.

Vertigo: A common problem that left one man teetering for months and months

March 27, 2009. I was fine the night before. The little cold I’d had was gone, and I’d had the first good night’s sleep all week. But when I woke up Friday morning at 6:15 and got out of bed, the world was whirling counterclockwise. I knocked against the bookcase, stumbled through the bathroom doorway and landed on my knees in front of the sink. It was as though I’d been tripped by a ghost lurking beside the bed.

Even when I was on all fours, the spinning didn’t stop. Lightheaded, reaching for solid support, I made it back to bed and, showing keen analytical insight, told my wife, Beverly, “Something’s wrong.”

The only way I could put on my shirt was to kneel on the floor first. I teetered when I rose. Trying to keep my head still, moving only my eyes, I could feel my back and shoulders tightening, forming a shell. Everything was in motion, out of proportion, unstable. I barely made it downstairs for breakfast, clutching the banister, concentrating on each step and, when I finally made it to the kitchen, feeling too aswirl to eat anyway. I didn’t realize it at the time, but those stairs would become my greatest risk during this attack of relentless, intractable vertigo.

Vertigo — the feeling that you or your surroundings are spinning — is a symptom, not a disease. You don’t get a diagnosis of vertigo; instead, you present with vertigo, a hallmark of balance dysfunction. Or with dizziness, a more generalized term referring to a range of off-kilter sensations including wooziness, faintness, unsteadiness, spatial disorientation, a feeling akin to swooning. It happens to almost everyone: too much to drink or standing too close to the edge of a roof or working out too hard or getting up too fast.

But according to the National Institutes of Health, “more than four in 10 Americans will experience an episode of dizziness sometime during their lives that’s significant enough to send them to a doctor.” That would be approximately 125 million of us.

If it came with a soundtrack, vertigo’s would sometimes be a train’s wheels grinding and screeching on the tracks as the car turns and almost tips over. Other times it would be a treetop filled with the ruckus of rioting crows in a sudden windstorm.

I remember feeling helpless and untethered, needing to reach out for something stable to steady me but finding that there was too much give in everything I sought. Vertigo is a carnival world and I was the Human Bumper Car. I moved without authority because the simple act of shifting my head’s plane threw me into chaos. But so did remaining motionless. I was never comfortable or relaxed, never at ease, at home in my world.

But I was not alone. In part, that was because I had Beverly’s support and my daughter’s steady concern. I was also not alone because, as a study published in the Archives of Internal Medicine in 2009 noted, 69 million Americans age 40 and older, or 35.4 percent of the population during the four-year study period, had some form of vestibular dysfunction — a term that includes vertigo.

When I was struck by vertigo, I had no idea it was such a common occurrence.

I was also not unfamiliar with balance problems. In 1988, I contracted a virus that targeted my brain and left me neurologically disabled. Besides damage to my memory systems, abstract reasoning, word-finding and other cognitive powers, my brain’s ability to process information — including information necessary to maintain balance reliably — had been compromised. I’d had to walk with a cane for 15 years.


Human balance is a multi-system operation. “It begins with a series of signals within the tiny balance organs of the inner ear,” according to hearing and balance expert Daniel Sklare. “These organs work with your brain’s visual system to give you a sense of your body’s position.” Other parts of the body — skin, joints, muscles — also relay balance information to the brain. All it takes to trigger a balance disorder is a malfunction in one of these delicate components. Researchers have identified more than a dozen different balance disorders, NIH reported in 2012.

On that March morning in 2009, my primary-care physician thought my problem was the most common of those disorders, benign paroxysmal positional vertigo, or BPPV. He explained that “ear rocks” — small deposits of calcium carbonate, probably dislodged by the viral infection I’d caught the week before at the coast — had collected in the inner-ear canals of my right ear. Such debris, or otoconia, jitters at the least movement and sends all sorts of confusing signals through the balance system. Until it dissolved, I could expect the symptoms to persist. It could last two days or two weeks or two months, he said.

It lasted five months. To be precise, by the time I’d seen the neurotologist — who spun me in an Omniax system chair, a diagnostic device that looks like a futuristic carnival ride or an apparatus for training astronauts to endure zero gravity — and the neurologist specializing in balance disorders — who sent me for an MRI of the brain and then left for a month’s vacation — and the acupuncturist, who was also a doctor of Chinese medicine, my vertigo had been going on for 138 days.

And it wasn’t BPPV, reasonable though that initial diagnosis seemed. Beverly and I had gone home and researched it. We watched several YouTube demonstrations of the Particle Repositioning Procedure, or Epley maneuver, intended to relocate the otoconia. I’d lie supine on our bed with my head turned to the right and dangling dizzily off the edge into Beverly’s hands. After 30 seconds, she shifted my head to the left, waited another 30 seconds and helped me rotate onto my left side, face down, where I looked at her kneecap. When 30 more seconds passed, I slowly sat up and gathered myself for a minute, trying not to puke. Three times a day.

For 69 days. Not that I was counting, but that was 1,656 hours of my life during which I had to walk with a cane, couldn’t safely manage the stairs, couldn’t drive, could barely endure being a passenger in a moving vehicle, fell in the grocery store while reaching for a package of paper towels, sagged to my knees while trying to walk along the street beside Beverly, couldn’t write or sustain focus on reading, grew lightheaded when tree limbs moved in a breeze or swallows changed direction in flight. Through all that time I felt so disembodied, while also feeling trapped inside my body, that I believed I was losing myself hour by hour.

My vertigo had never been benign in any sense of the word; had never been paroxysmal, since it didn’t come and go; had never been a function of position; had involved more than simply vertigo; and had not been resolved by 207 repetitions of the Epley maneuver (nor by drinking ginger tea). As a result, we thought I might not have benign paroxysmal positional vertigo. My doctor agreed.


After weeks of intensive testing — during which I had electrodes stuck deep in my ears, I was barraged by piercing sounds and by air puffed into my ear canals, and I was subjected to jerking/tilting floor platforms and those crazy loop-the-loops on the Omniax chair — I was given the diagnosis of endolymphatic hydrops. This condition, a fluctuation of the volume and concentration of fluid in the inner ear, can occur as a result of infection, allergy, tumor, degeneration of the inner ear, head trauma or unknown causes. In my case, the neourotologist thought the cause was a viral endolabyrinthitis — a virus attacking my inner ear. He felt it might be a reactivation of some earlier virus in my system, most likely the herpes zoster I’d contracted in 2002, when I had chickenpox for the first time at age 55.

Since the neurotologist prescribed a potent antiviral drug, Valtrex, I wanted to consult my primary-care physician again before taking the medication. He was skeptical of the diagnosis. After all, besides vertigo I had none of the classic symptoms of endolymphatic hydrops. My symptoms didn’t fluctuate according to position or activity, I had no hearing loss, no ringing or buzzing or feeling of fullness in the ear.

Technology and medical science confirmed that I was dizzy. They still didn’t know quite why.

On Day 95, I consulted with the neurologist, who talked about strokes in the brain stem and tumors and said, “Let’s have a look, so we can rule things out.” On Day 97, I had an MRI of the brain. On Day 101, my 62nd birthday and the day before the neurologist was heading off for a vacation, he called to say there was no sign of anything worrisome, though there might be a slight area of contact between a blood vessel and nerves of the inner ear. He thought I was in no danger unless I fell, so I shouldn’t fall. We’d meet when he returned. He prescribed a tiny dose of Valium twice a day to dampen nerve response in case there was that contact with a blood vessel.

At 8:09 on the evening of Aug. 12, Day 138, Beverly and I were sitting on the couch in our living room. It had rained all day. I’d had my ninth acupuncture treatment the day before. I was reading, slowly, Willie Morris’s memoir about his friendship with James Jones, when there was a great burst of outward pressure inside my head. It plugged my ears. I dropped the book, opened my mouth wide, put both hands to my ears. In two seconds, the pressure reversed, vanished.

“Did something happen?” Beverly asked.

Delighted that I could still talk, move both arms and shift position on the couch, I said, “I don’t think it was a stroke.”

She looked at me for several seconds and smiled. “Stand up. I wonder if your vertigo is gone.”

I did. It was.

Twelve days later, when I told the neurologist what had happened and that, except for some residual lightheadedness, the symptoms hadn’t returned, he said, “You were in such bad vestibular shape. I’d like to take credit for this, but I don’t think I can.

The vanishing, he felt, confirmed a theory he’d been considering: intracranial hypertension, a buildup of pressure inside my skull, brought on by a virus. A buildup of viral material in the spinal fluid plugged the holes through which the fluid normally drains. That led to a buildup of fluid and pressure, which caused the symptoms.

“So, it came unplugged on its own?”

“It’s a pretty elegant theory.” He smiled.

The symptoms haven’t returned. They’ve looked in on me occasionally, teasing — wooziness when I move my head quickly, lightheadedness when I look out the window or see great blue herons land in a swaying cottonwood tree — but that’s all. It’s been four years, eight months and 10 days.

Skloot’s most recent book is “Revertigo: An Off-Kilter Memoir.”

Pathophysiology, Office Treatment and Future Directions

BPPV is the most common cause of vertigo. It most often occurs spontaneously in the 50 to 70 year age group. In younger individuals it is the commonest cause of vertigo following head injury. There is a wide spectrum of severity from inconsistent positional vertigo to continuous vertigo provoked by any head movement. It is likely to be a cause of falls and other morbidity in the elderly. Misdiagnosis can result in unnecessary tests. The cardinal features and a diagnostic test were clarified in 1952 by Dix and Hallpike. Subsequently, it has been established that the symptoms are attributable to detached otoconia in any of the semicircular canals. BPPV symptoms can resolve spontaneously but can last for days, weeks, months, and years. Unusual patterns of nystagmus and nonrepsonse to treatment may suggest central pathology. Diagnostic strategies and the simplest “office” treatment techniques are described. Future directions for research are discussed.

1. History and Pathophysiology

Benign paroxysmal positional vertigo (BPPV) is the most common vertiginous disorder in the community. The cardinal symptom is sudden vertigo induced by a change in head position: turning over in bed, lying down in bed (or at the dentist or hairdresser), looking up, stooping, or any sudden change in head position. There is a wide spectrum of severity. Mild symptoms are inconsistent positional vertigo. Moderate symptoms are frequent positional attacks with disequilibrium between. When severe, vertigo is provoked by most head movements, giving an impression of continuous vertigo. The symptoms can last for days, weeks, months, or years, or be recurrent over many years.

The earliest reference to it may have been by Shakespeare in “Romeo and Juliet” [1] In Act I, Scene II [enter Romeo and Bevolio] Bevolio says “Tut man, one fire burns out another’s burning. One pain is lessen’d by another’s anguish; turn giddy, and be holp by backwards turning.” In the medical literature the first descriptions of positionally induced vertigo are attributed to Adler [2] and later Barany [3], who believed it was a disorder of the otolith organs. Barany elicited vertigo in a 27-year-old woman by turning her head from side to side in a supine position and noted “…there appeared a strong rotatory nystagmus to the right with a vertical component upwards, which when looking to the right was purely rotatory, and when looking to the left was purely vertical. ” In 1952 Margaret Dix (1911–1981) and Charles Hallpike (1900–1979) [4] at Queen Square Hospital, based on 100 patients, presented a symptomatological definition and a provocative positional test for what they called “positional nystagmus of the benign positional type.” For symptoms they note: “The story given by the patient is characteristically that the giddiness comes on when he lies down in bed or when he turns over in bed, or when such a position is taken up during the day; for instance lying down beneath a car or in throwing the head backward to paint a ceiling.” Their diagnostic test: “….the patient is first seated upon the couch with the head turned to one side and the gaze fixed firmly on the examiner’s forehead. The examiner then grasps the patient’s forehead firmly between his hands and briskly pushes the patient back into the critical position [30 degrees below the level of the couch and turned some 30 to 45 degrees to one side]. The reaction which results calls for some detailed description. ” As did Barany they noted a torsional nystagmus with the upper pole of the eye beating (fast phase) toward the ground and that it “fatigued” on retesting. Additionally, they observed a response latency of approximately 5 seconds, a crescendo and decline of nystagmus, and a reversal of the nystagmus as the patient sits up. To eliminate the possibility that the response could be induced by vascular occlusion from rotation of the neck they tested patients on an apparatus which avoided it. The same response occurred. In Britain Hallpike was a pioneer of temporal bone histology. The right temporal bone of 40-year-old woman with “positional nystagmus of the benign positional type…to the right with the right ear undermost” was examined. In the macula of the utricle, the otolithic membrane was absent. They concluded: “The general picture is one of chronic tissue changes resulting either from infection or trauma…” and “We are thus directed to the conclusion that the lesion is a peripheral one and in the labyrinth towards which, when undermost, the nystagmus is directed”. Hallpike provided further evidence for a peripheral cause by abolishing symptoms in two patients with a chemical labyrinthectomy of an acoustically dead ear [5] and in one patient by an eight nerve section [6]. Both Barany and Dix and Hallpike concluded that “positional nystagmus of the benign positional type” was caused by disorder of the utricular macula.

By the early 19th century the bony and some membranous structure of the inner ear were anatomically well described but their functions unproven. Common notions were the following. The cochlea was responsible for mediating the nature and pitch of sound; the saccule and utricle were for perception of loudness, and the semicircular canals for transmission of bone-conducted sound and perception of sound direction [7]. Marie-Jean Flourens (1794–1867) was a professor of comparative anatomy in Paris, and in 1824 he published his experimental results on pigeon semicircular canals [8]: “If the membranous ducts are injured, a painful sensitivity to tones is observed, accompanied by abrupt and violent movements of the head…. If the horizontal canals are severed, the animal turns on its vertical axis; if the posterior vertical canal is severed the animal rolls over backward, and if the anterior vertical canal is severed the animal falls forward….” Flourens concluded that the semicircular canals inhibited motion (“forces moderatrices”) and influenced direction of motion, rather than having a role in balance. Flourens’ work had been largely ignored but was known to Prosper Meniere and acknowledged in his final paper in 1861 [9]. According to Adam Politzer (1835–1920) in his “History of Otology” [10] “the realization that the vestibular and semicircular canal structures are not organs of sound perception, that sound perception is transmitted solely through the cochlea, is the single most important result of Flourens’ experiments”. However it was another sixty years until a more sophisticated understanding of semicircular canal functions and their generated nystagmus was achieved by Julius Ewald (1855–1921) who was later Professor of Physiology at the University of Strassburg (now Strasbourg). In pigeons, he cannulated each semicircular canal and applied negative and positive pressures and observed the directions and intensity of the induced nystagmus [11]. The two major findings have become known as Ewalds’ Laws: (1) the direction of the induced nystagmus is in the plane of the canal being stimulated, and (2) in the horizontal canal an ampullopetal (towards the vestibule) movement of endolymph causes the greatest response where as in the posterior and superior canals an ampullofugal (away from the vestibule) endolymph movement causes the greatest response. At the time the differences were perplexing, as expressed by a writer in 1920 [12]: “It is, however, difficult to imagine how the same endolymph current can be stimulating for the one endorgan and hindering for the other”.

Thirty years later the advent of the electron microscope allowed a more detailed view of inner ear ultrastructure. In 1954 Wersall [13] showed that each vestibular sensory cell has one kinocilium and many stereocilia. The finding of morphological polarization of kinocilia on vestibular sensor cells [14, 15] explained Ewald’s paradox. In horizontal canal cristae the kinocilium is on the vestibule side of the stereocilia; in the posterior and superior canals the kinocilium is on the canal side of the stereocilia (Figure 1). In the 1960s, experiments in cats [16] clarified the relationship between canal receptors and extraocular muscles. Each receptor is connected to one ipsilateral and one contralateral muscle. The second order neurones are either excitatory (to the agonist muscles) or inhibitory (to the antagonist muscles) (Figures 2, 3, 4, and 5).

In 1962 Harold Schuknecht (1917–1996) at Harvard University in Boston [17] proposed that BPPV “might be caused by detached utricular otoconia, acting upon the cupula of the posterior semicircular canal. Although at that time there were no confirming human pathological studies, the concept seemed plausible from a purely theoretical point of view. ” In 1969 Schuknecht [18, 19] confirmed finding basophilic staining masses attached to the posterior canal cupula in patients who had had BPPV symptoms. He called this cupulolithiasis (heavy cupula) and assumed the masses were detached utricular otoliths which were removed by decalcification in preparation. This was supported by Gacek’s report of five patients where the selective resection of the posterior ampullary nerve abolished BPPV symptoms [20]. Cupulothiasis became the dominant theory for nearly thirty years, although it did not explain the variable and often long latency and fatiguability of the nystagmus. It was the impetus for two early specific treatments. Previously “treatment” had been by Cawthorne’s exercises in which the patient was instructed to repeat continually any movement which caused the vertigo until it ceased, on the assumption that central adaption was occurring [21]. Based on the cupulolithiasis theory Brandt and Daroff [22] devised an inpatient treatment where subjects lay down to the provocative side, sat up for thirty seconds, and then lay to the other side every three hours. After seven to ten days, 61 of 67 subjects were free of symptoms. The assumed aim was detachment of the particle from the posterior canal cupula. In France Semont (a physiotherapist) and Sterkers [23, 24] modified this to a logical physician-controlled treatment they called the Liberatory maneuver, now known as the Semont maneuver (Figure 6). The patient is lain down to the side of the symptomatic ear, facing down. When the nystagmus ceases, the patient is moved rapidly through 90 degrees to the opposite side (where the symptomatic ear becomes uppermost). Either immediately or up to 15 seconds later the patient experiences vertigo and has nystagmus identical to the symptomatic side. The technique was little known outside France.

In attempting to explain the latency and fatiguability of BPPV nystagmus, Hall et al. [25] (at the University of London, Ontario) and later Epley [26] (a solo private practice otologist in Portland, Oregon) made models of the semicircular canals and proposed that they were better explained by free-floating particles in the posterior canal, which Epley called canalithiasis. Also at the University of London, Ontario, Parnes and McClure, in attempting a surgical posterior canal occlusion, observed and photographed free otoconia in the endolymphatic compartment [27]. Based on his models Epley proposed a controlled set of head movements he called the canalith repositioning procedure (CRP) [28] (Figure 7). Epley had presented this as an instruction course at the American Academy of Otolaryngology, Head and Neck Surgery meetings since 1980 and endured considerable derision because he used a heavy massage vibrator over the mastoid process [29]. After seeing canaliths at operation, Parnes [30] described an almost identical particle repositioning maneuver (PRM) (often known as the Modified Epley maneuver) whose main difference is its slower pace.

BPPV (85% posterior canal) is now recognized as the most common cause of vertigo in adults. It is estimated that 2.4% of people experience at least episode in their life [31]. 9% of residents in a home for the elderly were found to have BBPV [32]. The onset is most commonly between the fifth and seventh decades. It is the most common cause of vertigo after a head injury [33, 34]. An episode of vestibular neuritis [35] and a period of bed rest [36] are common antecedents. Omission of a simple clinical test can result in patients undergoing unnecessary, expensive investigations [37].

Previously “nontypical” forms of positionally induced nystagmus were assumed to always have a central cause. While performing CRPS, Epley observed a sudden change of “typical” torsional posterior canal nystagmus to horizontal direction-changing nystagmus and deduced the nystagmus that would be caused by otoconia in the horizontal and even the superior canal [38]. Without clinical proof Epley predicted the logical treatment for horizontal canal BPPV would be a 360 degree horizontal plane rotation away from the symptomatic ear. In 1985 McClure [39] had published the electronystagmographic (ENG) traces of seven subjects who had intense positional vertigo and direction-changing horizontal nystagmus when supine. The fast phase was towards the undermost ear (geotropic). McClure suspected a “viscous plug” in the horizontal canal which was causing a piston effect on the horizontal canal receptor. As discovered by Ewald, an ampullopetal (towards the vestibule) cupula deflection is known to cause the most intense nystagmus and vertigo. Horizontal canal BPPV was then reported by others [40–43] and its particularly intense vertigo confirmed. Early repositioning attempts failed [41]. A 270 degree “barbecue” rotation was trialled [44].

These simple horizontal repositioning techniques remain the usual way of treating the horizontal variant of BPPV (Figure 10). Occasionally the most intense nystagmus is away (apogeotropic) from the undermost ear, implying a particle or particles attached to the cupula, or close to it, on its canal or utricular side [43, 45–47]. The cupula becomes “heavy” and is ampullofugal when the symptomatic ear is undermost and ampullopetal when it is uppermost. It can be difficult to ascertain which is the symptomatic ear, but it is likely to be the undermost ear which initiates the least nystagmus (Figure 4). Horizontal canal BPPV comprises approximately 15% in most series. As for posterior canal it can occur de novo, after mild head injury or by “canal conversion” during posterior canal repositioning [45, 46]. It is likely that patients with horizontal canal BPPV inadvertently treat themselves by rolling over in their sleep, if it is in the desirable direction. It they turn in the “wrong” direction they trigger and awake with vertigo.

Although Brandt et al. [48] in 1994 had alluded to “the rare anterior [superior] canal BPPV, the spontaneous symptoms occur when the affected ear is uppermost”, the first detailed description of superior canal BPPV is usually attributed to Herdman and Tusa [49] who documented two patients whose positionally induced nystagmus was accompanied by downbeat and torsional nystagmus likely to be caused by a superior canal receptor and which ceased after repositioning treatment, implying it was rare form of BPPV. Subsequently superior canal BPPV was recognized and reported by others [50–56] in whose series it accounts for approximately 1% of all BPPV diagnoses. In a review [52] of 50 consecutive patients with positionally induced nystagmus, 75% had a central cause: multiple system atrophy, cerebellar degeneration, and other miscellaneous causes with immediate onset of downbeat nystagmus on a Dix Hallpike test. In 25% (“idiopathic”) a Dix Hallpike test or a head-hanging test elicited downbeat nystagmus with a short latency. In half the subjects a torsional nystagmus could be seen through Frenzel glasses, but in one it was only discernible by video imaging. Aw et al. [54] studied forty-four patients whose BPPV had not responded to conventional repositioning, using 3-dimensional research coils and a 2-axis whole-body rotator. Seven had downbeat nystagmus with a small torsional component, and all responded to a “head-over-heels” forward rotation in the plane of the superior canal. Differences in the ampullary segments of the posterior and superior canals most likely explain why superior canal BPPV downbeat nystagmus can be triggered by a Dix Hallpike test to either side and for its small (or absent) torsional component. In most cases the symptomatic ear is the uppermost ear (Figure 5).

2. Office Management

The author uses the simplest repositioning techniques.

2.1. Posterior Canal BPPV

Diagnosis is by the Dix Hallpike test. Older patients with neck, back, and hip problems require special care, and the test can be more simply done over a pillow (Figures 2 and 5). The patient MUST experience vertigo. Occasionally an initial negative test may become strongly positive after the patient does vigorous headshaking.

The most common repositioning treatment is Epley’s CRP as modified by Parnes with one-minute pauses between head positions (Figure 7). Following the CRP a repeat Dix Hallpike test is done. If positive, the CRP is repeated with mastoid vibration (Hitachi Magic Wand 250 Hz massage vibrator). If the test is negative, no further repositioning is done. However it is NOT confirmation of treatment success, and retesting should be done. There is no widely accepted interval. One week is a reasonable goal. Younger, agile patients can be shown how to conduct their own follow-up test at home by lying down over a cushion on the floor (Figure 8). However, older patients, who often report success by avoiding provocative positions, MUST be seen and formally retested.

If at followup the Dix Hallpike test is positive, repeat treatment can be by a further CRP with mastoid vibration or by the Semont maneuver. Descriptions of the Semont maneuver typically show the patient held and moved by two hands around the neck. This is extremely inappropriate for many individuals who are larger, obese, or who have neck problems. A safer technique is for the physician to rapidly move the patient from side to side by a hand under the downmost shoulder (symptomatic ear) and the other supporting the neck (Figure 9).

A Cochrane collaboration review of the Epley CRP and 5 subsequent random controlled trials found a significant success compared with nontreated controls [57, 58]. Comparison of trials is confounded by variation in the number of CRP cycles used per treatment, clinician experience, and the treatment setting. There have been relatively few trials [59, 60] confirming the efficacy of the Semont maneuver compared with sham treatment. The Semont maneuver is the most logical first treatment for a patient with posterior canal cupulithiasis (immediate nystagmus onset) with attached otoconia more likely to be dislodged by a centrifugal force.

Epley initially recommended that after a CRP the patient should sleep propped up for two nights to prevent repositioned particles from returning [28]. However, numerous studies have not shown any advantage from posttreatment restrictions [61, 62]. The use of adjunctive mastoid vibration has remained contentious, probably because of the power range of the devices used [63].

The vast majority of BPPV treatment studies have been performed in specialist practice settings. While very few patients can or even wish to administer self-treatment, it is an understandable goal. Self-administered CRP at home after initial office CRP achieved a slightly greater improvement [63]. As an adjunct to self-treatment the newly released “DizzyFix” dynamic visual device (Clearwater Clinical) [64] significantly improved the performance of volunteers learning Parnes’ modification of the CRP (Figure 10). It is a useful teaching tool on correct CRP technique for patients and health professionals.

2.2. Horizontal Canal BPPV

Horizontal canal BPV is most likely to be discovered as the patient is undergoing a Dix Hallpike provocative test [46, 47]. Occasionally it suddenly becomes apparent (“canal Conversion”) after a CRP, with brisk horizontal-rotatory nystagmus. If there is pillow under the shoulders, it is removed and the patient is moved down the examination couch so that the head is midline and in the horizontal plane. Then the head is gently turned to one side and then the other (“head roll” test). Usually there is a clear, repeatable pattern of brisk nystagmus towards one undermost ear (maximum geotropic) and then weaker nystagmus (apogeotropic) when the opposite ear is down. If a “canal conversion” has occurred, the symptomatic ear is already known. The vertigo tends to be more intense than for posterior canal BPPV, and some patients become nauseated and require an antiemetic. Once the symptomatic ear has been identified, the mechanism and its different repositioning in the horizontal plane (“barbecue” repositioning) are explained to the patient (Figure 11). With the examiner seated at the head of the examination couch the patient is asked to rotate 360 degrees in four stages, a minute apart. At the third position the patient should be resting on the elbows with the neck flexed, so that the horizontal canal is vertical, which is where the particle will exit the canal if it has been successfully moved. The head roll test is repeated and, if negative, treatment ceases.

If on the head roll test the nystagmus is apogeotropic, the likely mechanism is cupulolithiasis in the undermost ear with the least nystagmus. The particle(s) could be on either side of the cupula. On the presumption it is on the canal side the standard direction rotation is carried out. If unsuccessful (likely vestibule side) rotation is done in the opposite direction. Additional headshaking or mastoid vibration can be used. Sometimes apogeotropic nystagmus reverses to geotropic, implying that an attached particle(s) has become free. If there is not a clear pattern, or if the patient becomes very nauseated, it is advisable to retest on another day. Central pathology must be kept in mind.

2.3. Superior Canal BPPV

On a Dix Hallpike test if there is downbeat nystagmus superior canal, BPPV is a possibility. If the cause is central, the nystagmus onset is immediate, and the patient does NOT experience vertigo. If it is BPPV, there will be a latency of onset and the patient MUST experience vertigo. Any torsional component may be imperceptible to the naked eye. Repeating the test with the head lower (“head-hanging” test) than usual may intensify the response. The particle may be in either ear but most likely in the uppermost ear. On these assumptions there are two simple “office” treatments.

The first is the Epley CRP performed with “head hanging” and commencing with the suspected ear uppermost. The second is the Li maneuver [65] where the patient is moved rapidly from a supine (midline) head-hanging position to a face-down position at the opposite end of the couch (Figure 12).

2.4. Recurrences, Failed Office Treatment, and Complications

Reported rates of spontaneous complete resolution of BPPV at a month range from 20% to 80%. The American Academy of Otolaryngology, Head and Neck Surgery Clinical Practice Guideline, Benign Paroxysmal Positional Vertigo recommends that physician retesting at one month after repositioning treatment should be the standard interval after treatment [58].

Patients treated for BPPV should be told that there is a likelihood of recurrences. Most trials involve a short follow-up period. In trials with longer followup the recurrence rate at one year is estimated at 15% [66] and 37%–50% at 5 years on the Kaplan-Meier curve [66, 67]. Posttraumatic BPPV may have a higher recurrence rate than spontaneous BPPV [68].

The most common “complication” of BPPV repositioning treatment is canal conversion. Considering the population age in which it is usually performed there is a surprising sparsity of literature on cervical spine and neurological complications [69].

2.5. Central Pathology

Central nervous system disorders can masquerade as BPPV, in particular intracranial tumours [52, 70, 71] and migraine. Nystagmus features which strongly suggest a neurological cause are downbeat nystagmus, direction-changing nystagmus without a change in head position, nausea with up or downbeating nystagmus, and preexisting and continuing nystagmus. The cardinal distinguishing feature from BPPV nystagmus is that the patient does NOT experience brief rotational vertigo. Therefore patients with such nystagmus or symptoms of BPPV not showing resolution after repositioning require neurological examination and MRI scanning of the brain and posterior fossa.

Migraine is now a well-recognised cause of recurrent vertigo [72]. During an episode positional testing can elicit upbeat torsional or horizontal nystagmus similar to BPPV [73, 74]. Features supporting migraine as a cause are headache, absence of brief acute vertigo induced by the Dix Hallpike test, disappearance of all nystagmus within days, and a recurrent pattern.

3. Future Directions

Currently Epley’s canalith theory explains most of the features of BPPV: the latency and type of nystagmus, according to the involved canal, and the logic and efficacy of repositioning treatments. However, as for many other inner ear disorders, certain details of its pathophysiology, in particular spontaneous recovery, remain elusive, largely due to the inability to internally image the inner ear in enough detail and the prior reliance on histological techniques. Increased knowledge of human otoconial physiology and pathology will be important.

As episodes of BPPV recover without treatment, it is reasonable to assume that otoconia exit a canal during normal head movement, particularly in horizontal canal and superior canal BPPV. It has been demonstrated that frog otoconia rapidly dissolve in endolymph with physiologic calcium levels, but more slowly if the calcium level is raised [75]. Therefore a major reason for spontaneous recovery is the ability of normal endolymph to dissolve otoconia if they do not return to the utricle. In mammals otoconia are calcite crystals of calcium carbonate. In rats scanning electron microscopy (EM) shows a progressive degeneration of otoconial structure in the oldest rats [76], a phenomenon consistent with the common age range in BPPV. In female rats made artificially oesteopenic/osteoporotic, scanning EM shows ultrastructural changes in otoliths [77] suggesting that there could be relationship between bone biochemistry and recurrent BPPV in older women. Seventy-five percent of thirty-two women aged been 50 and 85 years who had BPPV were shown to have osteopenia or osteoporosis compared with eighty-three healthy controls [78].

Measurement of vestibular-evoked myogenic potentials (VEMPs) is new electro-physiological technqiue for measuring saccule and otolith function. In some patients with vestibular neuritis absence of the cervical VEMPs(c-VEMP) on the side neurolabyrinthitis predicted the nondevelopment of BPPV which only occurred if the cVEMP was present. More recent studies on the “health” of the otolith organs using c-VEMPs [79, 80] have shown significantly large number of prolonged responses in patients with BPPV compared with healthy controls, suggesting neuronal degeneration of the saccule. In contrast newer ocular VEMPs (o-VEMP) also measure utricular function and are likely to be more relevant in establishing otolith dysfunction and recovery in BPPV. Distortion of the visual horizontal due to ocular torsion occurs in utricular dysfunction, as in vestibular neuritis. Measurement of the visual horizontal in BPPV patients was abnormal in 42% before-treatment, 15% after repositioning and in 8% two weeks later suggesting initial utricular dysfunction and its possible restoration from the return of otoliths [81]. Encouraging advances in imaging may eventually enable in vivo correlation. Three-dimensional T2-weighted 3-dimensional fast MRI imaging with steady-state acquisition sequences can now show some reliable detail of semicircular structure such as narrowed areas and “filling defects” [82]. In patients with “intractable” BPPV 89% had abnormal canals compared with healthy controls, but there was no correlation between the affected canal and nystagmus type. Subtle variations in canal diameter, length, and width may correlate with a predisposition to BPPV and to treatment failures.

Finally, the American Academy of Otolaryngology, Head and Neck Surgery Clinical Practice Guideline on BPPV [58] has recommended sixteen aspects meriting further research, including the true prevalence and burden of untreated BPPV in older adults, the natural history of untreated BPPV, agreed endpoints for clinical trials, and importantly the functional impact of BPPV on work safety and the rates of falls it may account for in the elderly.

Conflict of Interests

The author declares that there is no conflict of interests.


To Debbie Ware at Slipstream Creative (http://www.slipstreamcreative.co.nz) for illustrations. Video 2 in supplementary material that was available online at doi: 10.1155/2011/835671 (Semont manoeuvre) was filmed by Dr Stuart Mossman, Department of Neurology, Wellington Hospital, Wellington, New Zealand.

Supplementary Materials

The supplementary videos show examples of BPPV from the posterior, horizontal and superior canals, and a Semont maneuver for right posterior canal BPPV.

  1. Supplementary Material

90,000 “Postcoid syndrome is very dangerous.” What problems did coronavirus

survivors face?

In addition, there are those who have impaired blood flow, since during the treatment of COVID-19 they took anticoagulants (blood thinning drugs) uncontrollably.

Experts note that the coronavirus not only causes an exacerbation of chronic diseases, but itself remains in the human body for a long time, which slows down the healing process, therefore, in addition to treating the disease, such patients also need psychological rehabilitation.

In Kyrgyzstan, the outbreak of COVID-19 began in March. Domestic doctors at that time did not have complete information about how the disease affects people’s health and what the process of their rehabilitation should be. After massive cases of infection in June and July, the Ministry of Health of the Kyrgyz Republic decided to include instructions in the IV protocol for treating coronavirus for restoring people’s health after an illness.

“One disease replaces another”

Dinara Chokoeva contracted the coronavirus in early July.Despite the fact that she recovered, to this day she has to be treated for other ailments:

– When I contracted the coronavirus, an old head injury that I received in infancy, at the time of birth, immediately made itself felt. I had a headache before, but this time it was very bad. The treatment took about 14 days, the first week she received droppers, then – pills. After that, I stayed at home for another 15 days. The doctors said that “now the virus is not scary,” and I went to the village.But there I again either caught a cold, or something else, but my arms and legs began to hurt again, and again I had to lie under IVs for three days. After that, a small rash started all over my body. In general, one disease replaces another. All the same, the virus, it turns out, weakens a person – you sweat, there is no strength, as before. And when I already thought that I had recovered, my traditional allergy began. As soon as I managed to defeat her, taking medications, two days later the hand that I had broken 2-3 years ago reminded of itself.In general, the experts, apparently, were right when they said that the effects of the virus are felt for 2-3 months after recovery. My working capacity has decreased, I do not want to do anything. I saw poorly before, but now my vision has deteriorated even more.

“Many have problems with blood clotting”

Who wished to remain anonymous employee of the Ambulance Service of the city of Bishkek said that recently the number of complaints from citizens who, due to uncontrolled intake of blood thinning drugs (anticoagulants), had problems with blood vessels has increased:

– Firstly, after suffering a coronavirus infection, any deterioration in health is similar to the symptoms of a virus. Secondly, in the wake of panic in June and July, many citizens began to inject themselves with anticoagulants, such as heparin, clexane, which led to blood thinning. Now it is worth giving them the simplest injection – the blood does not stop at the site of this small wound, does not clot. Postcoid syndrome is a very dangerous thing, and it turns out that we don’t even know how to prevent it.

In IV the protocol provides for rehabilitation issues

Today in the Kyrgyz Republic, 1 thousand 21 patients receive treatment for coronavirus in hospitals, another 4 thousand 563 people are treated on an outpatient basis.

The chief infectious disease specialist of the Kyrgyz Republic Ainura Kutmanova says that a strong deterioration in the health of patients after suffering a coronavirus became noticeable during a large wave of infections that took place in July. In this regard, instructions for recovering from COVID-19 are now being introduced into the IV protocol of the Ministry of Health for the treatment of coronavirus:

– Basically, after this illness, many have an elevated temperature of 37‒37. 2 for a long time, headaches, sleep problems and impaired appetite.In addition, a depressed mood and hemodynamic disturbances were found. Due to the poor oxygen supply of blood, brain function begins to deteriorate, which leads to headaches. Therefore, everyone who has had this virus should begin rehabilitation immediately after they feel better. While still in the hospital, you can start doing breathing exercises. And one more important factor in the treatment of this disease is psychological support.

In addition, we noticed that getting sick, many people begin to feel fear, fall into depression, and this only intensifies the virus in the human body, and he succumbs to the disease.Therefore, it is necessary to monitor the emotional state of the sick person, he must be in a good mood. It is also healthy to eat small meals, but often. We usually eat 3-4 times a day, right? And after an illness, it is more correct to eat 5-6 times a day, that is, almost every two hours. Those with chronic diseases and heart problems, blood vessels should not stop taking medications that they drank constantly. We are now preparing to add this large section on rehabilitation after COVID-19 to Protocol IV.Because we didn’t have this information before.

Affects the nervous system

As of August 26, in Kyrgyzstan, the number of confirmed cases of COVID-19 reached 43 thousand 358. Over the past day, 292 people have recovered from this infection. And in total during the period of the epidemic – 37,217 patients. Over the past day, one death from coronavirus was recorded in Bishkek. The total number of victims of COVID-19 in the Kyrgyz Republic since the beginning of the epidemic has amounted to 1 thousand 58. Recall, on August 18, the Ministry of Health of Kyrgyzstan revised the statistics on COVID-19, after which the mortality rate decreased by almost a third.

Nurse from Kyrgyzstan, Sairagul Zholborsova , who lives in Moscow, noted the consequences of COVID-19 on the human body:

– The most important thing is that the work of the brain is disrupted. This virus is especially dangerous for those who have diseases of the kidneys, lungs, cardiovascular system, as well as chronic diseases. COVID-19 causes blood clots to form, which sometimes leads to brain hemorrhage. And since the immune system is weakened, neurological diseases such as encephalitis, stroke, as well as heart attacks and drops in blood pressure begin to appear.All this leads to the fact that muscles begin to ache, a person has no strength for anything, his working capacity decreases. Therefore, those with chronic diseases need to be especially careful.

Good hygiene practices must be followed

Coronavirus practically proceeds in the same way as acute respiratory diseases, but differs in that the disease quickly goes down into the lungs, which causes pneumonia. Despite the fact that the wave of infections has subsided, it is still necessary for those with chronic diseases to take care of themselves in order to protect themselves from re-infection and the complications caused by this virus.

Doctor Ulanbek Usubaliev says that one should not neglect basic hygiene standards, considering that the virus has come to naught and that the person has already recovered:

– During computed tomography, it is clearly seen that in those who have had coronavirus for 2-3 months after recovery, changes in the lungs persist. In other words, in a person infected with COVID-19, the lungs recover over a long time. This suggests that the blood flow is disturbed, there is little oxygen in it.And self-administration of various medications also entails negative consequences. Therefore, after recovery, it is necessary to constantly be in touch with the doctor, not to remove the mask, to maintain social distance and hygiene.

In Kyrgyzstan, today, public hospitals do not provide rehabilitation services after coronavirus, perhaps they are available in private clinics. According to doctors, due to the use of strong antibiotics, some patients are resistant to antibiotics in general, as well as problems with the stomach and digestive system.


Translation from Kyrgyz. The original article is here.

90,000 Doctors explained why people who have had COVID-19 feel tired

About 52.3% of those who have recovered from COVID-19 complain of rapid fatigue and a feeling of fatigue, scientists from Dublin found. At the same time, these symptoms are also recorded in patients with a mild course of infection. Doctors explained to Gazeta.Ru that there can be many reasons for this condition: pulmonary tissue fibrosis, decreased activity, or post-coronavirus syndrome.

Fatigue and fatigue do not disappear in more than half of people who have recovered from COVID-19. This is the conclusion made by Irish scientists.

The researchers used the Chalder Fatigue Scale (CFQ-11) to measure fatigue in recovered patients. In addition, the severity of the patient’s initial infection was taken into account – whether hospitalization was required, as well as any other pre-existing conditions that could contribute to fatigue, such as depression.

About 56% of patients assessed the need for hospitalization in the event of this symptom, and 44.5% opposed it. By the end of the tests, the researchers determined that more than half of the participants – 52.3% – reported “persistent fatigue” even after they recovered.

Moreover, even those patients who did not need hospitalization, that is, their illness was easier, still reported constant fatigue after infection.

“There was no link between the severity of COVID-19, the need for hospitalization, supplemental oxygen or intensive care, and fatigue after coronavirus.In addition, there was no association between standard laboratory markers of inflammation and cell turnover and fatigue, ”said co-author 90,095 of Study , Dr. Liam Townsend of St. James’s Hospital and the Institute for Translational Medicine at Trinity College Dublin.

It is noted that most of the participants in the experiment who complained of fatigue are women. Among the patients there were also those who did not record this state in their state of health, but noted depressive and anxious moods.

Meanwhile, as explained to Gazeta.Ru, the pulmonologist of the Russian National Research Medical University named after N.I. Pirogova Anna Sergeeva, one of the causes of fatigue may be shortness of breath, which is often experienced by those who have had a coronavirus infection.

“It interferes with patients’ daily work as COVID-19 affects lung tissue. Consequently, a person needs to breathe more often due to a decrease in lung volume, which results in fibrosis, that is, scarring of lung tissue due to the fact that the body replaces damaged cells with tougher and denser tissues, ”the doctor notes.

As a result of scarring, the elasticity of the lungs deteriorates, and when a person inhales, the tissues stretch less and let less air into the lungs. According to her, this condition should go away 2-3 months after the illness.

“But if the symptoms persist, then an urgent need to see a doctor. It is better to exclude the consequences at once, than to suffer all your life later, ”the specialist concluded.

Rehabilitation therapist and physiotherapist Mikhail Valiev, in turn, believes that in many cases, fatigue appears after suffering stress against the background of COVID-19, and is also due to a decrease in activity during treatment.

“Even if you carried it on your feet, the body has been struggling all this time, and when you have recovered, a feeling of fatigue may well develop.

It should be remembered that long-term weakness is not a specific phenomenon for viral infections: this happens after any disease that disrupts the normal functioning of the body, “Valiev emphasizes.

In turn, psychotherapist Lilia Koroleva notes that such fatigue can develop against the background of post-coronavirus syndrome.According to her, 2-4 months after the first signs of the disease, when a person has already recovered, but feels bad, some people notice symptoms such as fatigue, fatigue and joint problems. Someone has pains in the kidneys, heart and liver.

“After recovery, many people continue to measure their temperature 20 times a day, read a bunch of inaccurate information on the Internet and, as a result, ascribe to themselves certain post-like symptoms. Including fatigue, ”she told Gazeta.Ru ”doctor.

She added that those who have recovered from COVID-19 often feel weak against the background of the stress they have endured. In her opinion, in order to get rid of fatigue, they need to undergo not only physical rehabilitation, but also psychological.

“Against the background of nerves and weakened immunity, people can pick up some other sore. At the same time, they will consider that these are simply the consequences of a coronavirus infection, and most likely they will not go to a doctor, ”concluded the Queen.

Post-traumatic stress

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PTSD is a normal reaction
to serious traumatic events.
This booklet addresses the signs
symptoms and treatments for PTSD.

New York State
Department of Mental Health

Have you experienced a terrible and dangerous event? Note,
please, those cases in which you recognize yourself.

  • Sometimes, for no apparent reason, as if everything that happened to me happens
    again. I never know when to expect it again.
  • I have nightmares and are tormented by the memories of that terrible incident,
    which I have experienced.
  • I avoid places that remind me of that incident.
  • I jump in place and feel uncomfortable with any sudden
    movement or surprise. I feel alert all the time.
  • It’s hard for me to trust someone and get close to someone.
  • Sometimes I just feel emotionally drained and deaf.
  • I am very easily pissed off.
  • I am tormented by a feeling of guilt that others have died and I have survived.
  • I do not sleep well and have muscle tension.

PTSD is a very serious condition that needs treatment.

Many people who survived terrible events suffer from this ailment.

It is not your fault that you got sick, and you should not suffer from it.

Read this booklet to find out how you can be helped.

You can get well and enjoy life again!

What is Post Traumatic Stress Disorder (PTSD)?

PTSD is a very serious condition. PTSD symptoms may occur in
a person who has experienced a terrible traumatic event. This ailment succumbs
drug therapy.

PTSD can occur after you:

  • Become a victim of sexual assault
  • Have been a victim of physical or emotional domestic violence
  • Become a victim of a violent crime
  • Have been in a car accident or plane crash
  • Survived a hurricane, tornado or fire
  • Been at war
  • Lived a life-threatening event
  • Become an eyewitness to any of the above events

In PTSD, you often have nightmares or eerie
memories associated with an experienced event.You try to hold on
away from anything that might remind you of your experience.

You are embittered and unable to trust anyone or care for others.
You are always on the alert and see a hidden threat in everything. It becomes not for you
on its own when something happens suddenly and without warning.

When does post-traumatic stress occur and how long does it last?

In most cases, PTSD manifests itself approximately
three months after the traumatic event.In some cases, signs
post-traumatic stress disorder manifests itself only years later. Post-traumatic
people of any age are exposed to stress. Even children are not immune from it.

Some get better after six months, while others may suffer from it
the disease is much longer.

Am I not the only one with this condition?

No, you are not alone. 5.2 million Americans suffer from PTSD every year.

Women suffer from this disease two and a half times more often than men.The traumatic events most commonly associated with PTSD in men are:
rape, participation in hostilities, neglect and abuse
in childhood. The most traumatic events in women are rape,
sexual abuse, physical assault, threat
weapons and childhood abuse.

What other conditions can be associated with PTSD?

Concomitant depression, alcoholism and drug addiction, or other common
anxiety disorders.The likelihood of successful treatment increases if these
concomitant diseases in time to identify and treat.

Frequent headaches, gastroenterological problems, problems with the immune
system, dizziness, chest pain or discomfort in others
parts of the body. It often happens that a doctor treats physical symptoms,
unaware that their cause lies in PTSD.

The National Institute for Mental Health (NIMH) recommends
therapists ask patients about their experiences of abuse, recent bereavements and
traumatic events, especially in cases where the symptoms are all the time
come back.Once PTSD is diagnosed, it is recommended that
a patient with a mental health professional who has
experience of treating patients with PTSD.

What do I need to do to help myself in this situation?

Talk to your doctor and tell him about your experience,
and how you feel. If you have terrible memories,
overwhelmed by depression and sadness if you have trouble sleeping and are constantly
angry – you should tell your doctor about all this.Tell him
do the listed conditions interfere with your daily activities and
lead a normal life. You can show your doctor this booklet.
This can help explain to him how you are feeling. Ask your doctor
examine you to make sure you are not physically ill.

Ask your doctor if he has had any patients with
post-traumatic stress. If your doctor does not have a special
preparation, ask him for directions to
a physician with relevant experience.

How can a doctor or psychotherapist help me?

Your doctor may prescribe medication to help ease your fear
or tension. However, it should be borne in mind that usually should pass
several weeks before the medicine takes effect.

Many people with PTSD benefit from talking
with a professional or other people who have experienced a traumatic event.
This is called “therapy.”Therapy can help you overcome your nightmare.

One Person’s Story:
“After I was attacked, I
constantly felt fear and depression, became irritable.
I could not sleep well and lost my appetite. Even when I tried not
thinking about what happened, I was tormented anyway
nightmares and terrible memories. ”

“I was completely at a loss and did not know what to do. One buddy
advised to see a doctor.My doctor helped me find a specialist in
post-traumatic stress. ”

“It took me a lot of strength, but after medication and a course
therapy, I gradually come to my senses. It’s good that I called my doctor then. ”

PTSD and the army

If you are a member of the military, you have probably taken part in the fighting. You,
most likely they were in dire and life-threatening situations. You’ve been shot at
you saw how your friend was shot, you saw death.Experienced
events can cause PTSD.

Experts say PTSD occurs:

  • Almost 30% of Vietnam War veterans
  • Almost 10% of Gulf War veterans
    (Operation Desert Storm)
  • Almost 25% of veterans of the war in Afghanistan (operations
    “Injecting Freedom”) and veterans of the war in Iraq (Operation
    “Iraqi Freedom”)

Other factors of the military environment can add stress to and
so stressful situations and can contribute to the development of PTSD and other mental
problems.Among these factors are the following: your military specialty,
the political aspects of the war, where the battle takes place and who your enemy is.

Another reason contributing to PTSD in military personnel is
sexual assault in the military (MST) – any kind of sexual harassment or
sexual assault during military service. MST can happen
with men and women, and can occur in peacetime, during a military
training or during the war.

Veterans with Veterans Affairs (VA) health care include

  • 23 out of 100 women (23%) reported sexual assault during
    military service
  • 55 out of 100 women (55%) and 38 out of 100 men (38%) were
    sexual harassment while serving in the army

Although the trauma of sexual assault in the military is more common
among women, more than half of veterans who have suffered a sexual injury
violence in the army is men.

Remember, you can get the help you need right now:

Tell your doctor what you have been through and how you feel.
If your doctor does not have specific training for the treatment of PTSD,
ask him for a referral to a doctor who has relevant experience.

Research on PTSD issues

To help those suffering from PTSD, National Conservation Institute
Mental Health (NIMH) supports research on PTSD,
as well as other topical PTSD-related research on
anxiety and fear.Research is challenged to find new ways to
help people cope with trauma, as well as find new treatment options and,
the main thing is to prevent the disease.

Research on possible risk factors for PTSD

Today, the attention of many scientists is focused on genes that play a role in
the occurrence of terrible memories. Understanding the mechanism of “creating” scary
memories can help improve or find new ways to relieve
PTSD symptoms.For example, PTSD researchers have identified genes that are responsible for:

Statmin – a protein involved in the formation process
terrible memories. During one experiment, mice were placed in
an environment designed to make them fearful. In this situation
mice lacking the statmin gene, in contrast to
normal mice were less likely to “freeze” – ie. exhibit
natural defensive reaction to danger. Also in the setting,
designed to cause innate fear in them, they demonstrated
less than normal mice, more willingly
mastering the open “dangerous” space. 1

GVP (gastrin-releasing peptide / GRP) – signaling substance
of the brain, released during emotional events. Have
mice, PRG helps to control the fear response, and the lack of
GWP can lead to a more prolonged
memories of fear. 2

Scientists have also discovered a variant of the 5-HTTLPR gene that controls the level of
serotonin (a substance in the brain associated with mood),
which, it turns out, fuels a fear response. 3 It looks like
in the case of other mental disorders, in the development of PTSD
different genes are involved, each of which contributes to the formation of the disease.

To understand the causes of PTSD also helps to study various sites
the brain responsible for fear and stress. One of these sites is
the cerebellar amygdala, which is responsible for emotions, assimilation of knowledge and memory.
It turned out that she plays an active role in the appearance of fear (or other
words, “teaches” to be afraid of something, for example, to touch a hot stove),
as well as in the early phases of fear extinguishing (or in other words, “teaches”
Do not be scared). 4

The storage of faded memories and the weakening of the initial fear response are linked.
with prefrontal cortex (PFC / PFC) of the brain, 4
responsible for making decisions, solving problems and assessing the situation. Each zone
PFC has its own role. For example, when the PFC believes that the source of stress is susceptible to
control, the medial prefrontal zone of the PFC suppresses the center of anxiety deeply
in the brain stem and controls the stress response. 5 Ventromedial PFC helps maintain
long-term fading of terrible memories, and on her ability to perform
this feature can be influenced by its size. 6

Individual differences in genes or characteristics of head regions
brains can only pave the way for PTSD, but not by themselves
cause no symptoms. Environmental factors such as
childhood trauma, head trauma, or mental illness in
family, favor the development of the disease and increase the risk of disease,
affecting the brain in the early stages of its growth. 7 Except
In addition, how people adapt to trauma is likely to be influenced by
and characteristics of character and behavior, such as optimism and a tendency to consider
problems in a positive or negative way, as well as social factors such as
availability and use of social support.
8 Further research may
show what combination of these factors or what other factors will allow
ever predict who has a traumatic event
will cause PTSD and who will not.

Research on the treatment of PTSD

Currently, psychotherapy is used in the treatment of PTSD
(“Talking” therapy), drugs or drug-therapeutic combination.


Cognitive Behavioral Therapy (CBT) helps you learn differently
think and react to frightening events that trigger development
PTSD, and can help bring symptoms of the disease under control.There are several types
cognitive behavioral therapy, including:

Collision Technique – Uses mental imagery, notes, or site visits
trauma to help those affected face the overwhelming
their fear and take control of it.

Behavioral restructuring (cognitive restructuring) – encourages
survivors of a traumatic event express depressing (often mistaken) thoughts about
experienced trauma, challenge these thoughts and replace them with more
balanced and appropriate.

Introduced into a stressful situation – teaches how to reduce
anxiety and coping with it, helping to ease the symptoms of PTSD,
and helps to correct erroneous trauma-related thoughts.
NIMH is currently conducting research to study the reaction
of the brain to cognitive behavioral therapy versus response
for sertraline (Zoloft) – one of two drugs recommended and approved
American Food and Drug Administration
agents (FDA) for the treatment of post-traumatic stress.This study can
help figure out why some people respond better to medications, and
others – for psychotherapy


Recently, in a small study, NIMH scientists found that if
patients who are already taking a dose of prazosin (Minipress) before bed,
add a daily dose, it reduces the general symptoms of PTSD and stress
reaction to reminders of the trauma experienced. 9

Another drug of interest is D-cycloserine (Seromycin),
which increases the activity of a substance in the brain called
N-methyl-D-aspartate needed to extinguish fear.During the research,
which was attended by 28 people suffering from a fear of heights, scientists
found that patients who received collision therapy before
D-cycloserine, showed lower levels of fear during the session
compared to those who did not receive the medicine.
10 Currently scientists
study the effectiveness of the combined use of D-cycloserine and
therapy for the treatment of post-traumatic stress.

Propranolol (Inderal), a beta-blocker drug, is also being studied
whether it can be used to ease post-traumatic stress and
interrupt the chain of occurrence of terrible memories. First experiments
gave comforting results: it was possible to successfully weaken and, it seems,
prevent PTSD in a small number of victims of traumatic events.

For example, in one preliminary study, scientists created a website
self-help based on the use of a psychotherapeutic method
introduction into a stressful situation.PTSD patients first meet with
a doctor. After this meeting, participants can visit the site to find
more information about PTSD and how to deal with the problem; their doctors
can also visit the site to give advice if necessary or
instruction. In general, scientists believe that therapy in this form –
a promising method of treating a large number of people suffering from
PTSD. 12

Scientists are also working to improve verification methods,
early treatment and follow-up of massive trauma survivors,
developing ways to teach them self-examination skills and
introspection and referral mechanism to psychiatrists (if necessary).

PTSD Research Prospects

In the last decade, rapid progress in the study of mental and biological foundations
PTSD has led scientists to the need to focus on prevention,
as the most realistic and important goal.

For example, to find ways to prevent PTSD, with funding
NIMH conducts research on the development of new and orphan drugs,
aimed at combating the underlying causes of the disease.In the course of another
research scientists are looking for ways to enhance behavioral, personal and
social protective factors and minimizing risk factors for
preventing the development of PTSD after trauma. Another study is doing
studying the question of what factors influence the difference in reaction to one or another
a way of treatment that will help in developing a more individual,
effective and productive treatments.

Where can I find more information?

MedlinePlus – Resource of the American National Library of Medicine
(U.S. National Library of Medicine and the National Institutes of Health) –
offers the latest information on many health issues. Information about
You can find PTSD at:


National Institute of Mental Health

Office of Science Policy, Planning, and Communications
[National Institute for Mental Health
Science Policy Division
Research, Planning & Liaison]
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513; Fax: 301-443-4279
Fax Answer System,
Toll Free Voicemail: 1-866-615-NIMH (6464)
Text Phone: 1-866-415-8051 Toll Free
nimhinfo @ nih.gov

National Center for Post-traumatic Stress Disorder

[National Post Traumatic Stress Center]
VA Medical Center (116D)
215 North Main Street
White River Junction, VT 05009


  1. Shumyatsky GP, Tsvetkov E, Malleret G, et al. Identification of a signaling
    network in lateral nucleus of amygdala important for inhibiting
    memory specifically related to learned fear.Cell. Dec 13 2002; 111 (6): 905-918.
  2. Hariri AR, Mattay VS, Tessitore A, et al. Serotonin transporter genetic variation and the
    response of the human amygdala.Science. Jul 19 2002; 297 (5580): 400-403.
  3. Milad MR, Quirk GJ. Neurons in medial prefrontal cortex signal memory
    for fear extinction. Nature. Nov 7 2002; 420 (6911): 70-74.
  4. 5 Amat J, Baratta MV, Paul E, Bland ST, Watkins LR, Maier SF.
    Medial prefrontal cortex determines how stressor controllability affects
    behavior and dorsal raphe nucleus.Nat Neurosci. Mar 2005; 8 (3): 365-371.
  5. Milad MR, Quinn BT, Pitman RK, Orr SP, Fischl B, Rauch SL. Thickness of ventromedial
    prefrontal cortex in humans is correlated with extinction memory. Proc Natl Acad Sci USA. Jul 26
    2005; 102 (30): 10706-10711.
  6. Gurvits TV, Gilbertson MW, Lasko NB, et al. Neurologic soft
    signs in chronic posttraumatic stress disorder.Arch Gen
    Psychiatry. Feb 2000; 57 (2): 181-186.
  7. Brewin CR.Risk factor effect sizes in PTSD: what this means for
    intervention. J Trauma Dissociation. 2005; 6 (2): 123-130.
  8. Taylor FB, Lowe K, Thompson C, et al. Daytime Prazosin Reduces
    Psychological Distress toTrauma Specific Cues in Civilian Trauma Posttraumatic
    Stress Disorder. Biol Psychiatry. Feb 3 2006.
  9. Ressler KJ, Rothbaum BO, Tannenbaum L, et al. Cognitive enhancers as adjuncts to
    psychotherapy: use of D-cycloserine in phobic individuals to facilitate
    extinction of fear.Arch Gen Psychiatry. Nov 2004; 61 (11): 1136-1144.
  10. Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of secondary
    prevention of posttraumatic stress disorder with propranolol.Biol
    Psychiatry. Jan 15 2002; 51 (2): 189-192.
  11. Litz BTWL, Wang J, Bryant R, Engel CC.A therapist-assisted Internet
    self-help program for traumatic stress. Prof Psychol Res Pr.
    December 2004; 35 (6): 628-634.

The New York State Department of Mental Health expresses
thanks to the National Institute of Mental Health for the information,
used in this booklet.

Published by the State Department of Mental Health
New York, June 2008.

New York State
Andrew M. Cuomo, Governor

Department of Mental Health
Head of Department Michael F. Hogan, Ph.D.
For more information on this edition, contact:
New York State Office of Mental Health
Community Outreach and Public Education Office
[New York State Department of Mental Health
Department of Public Relations and Community Outreach]
44 Holland Avenue
Albany, NY 12229
866-270-9857 (toll free)

For questions and complaints regarding mental health services
Health in New York, contact:
New York State Office of Mental Health
Customer Relations
[New York State Department of Mental Health
Customer Service]
44 Holland Avenue
Albany, NY 12229
800-597-8481 (toll free)

For information on mental health services in
your neighborhood, contact
New York State Department of Mental Health (NYSOMH) Regional Office Nearest:
Western New York Field Office
[Western New York Regional Office]
737 Delaware Avenue, Suite 200
Buffalo, NY 14209
(716) 885-4219

Central New York Field Office
[Central New York Regional Office]
545 Cedar Street, 2nd Floor
Syracuse, NY 13210-2319
(315) 426-3930

Hudson River Field Office
[Hudson River Regional Office]
4 Jefferson Plaza, 3rd Floor
Poughkeepsie, NY 12601
(845) 454-8229

Long Island Field Office
[Long Island Regional Office]
998 Crooked Hill Road, Building # 45-3
West Brentwood, NY 11717-1087
(631) 761-2508

New York City Field Office
[New York City Regional Office]
330 Fifth Avenue, 9th Floor
New York, NY 10001-3101
(212) 330-1671

Fomin’s Clinic – a network of multidisciplinary clinics

There are many methods of hormonal contraception, it is not easy to understand them.In this article, we answer the most common questions and consider in detail the pros, cons and subtleties of using hormonal contraceptives.

All processes associated with childbirth in the female body are controlled by hormones. With the help of drugs that contain synthetic analogs of female hormones, it is possible to prevent pregnancy even at the stage of egg maturation.

Modern hormonal contraceptives can do three things:

  • prevent the egg from leaving the ovaries – that is, they stop ovulation;

  • make the mucus in the cervix thick and sticky so that sperm cannot reach the egg and fertilize it;

  • disrupt the growth of the uterine lining (endometrium) – as a result, the fertilized egg cannot gain a foothold in the uterus.

This is usually enough to prevent pregnancy. Women who use hormonal contraceptives do not need a condom “for insurance,” but to protect themselves from sexually transmitted infections. Hormonal contraceptives do not protect against germs.

The British Ministry of Health estimates that hormonal contraceptives are more than 99% effective when used correctly. But even if you use them not quite according to the instructions (for example, take a pill at the wrong time, or skip taking one pill altogether), the result will still be quite reliable: about 91% effectiveness.

It is important to understand that there is no 100% reliable method of contraception. The staff of the World Health Organization (WHO) calculated the proportion of married couples who used hormonal contraceptives for a whole year in full accordance with the existing recommendations – that is, according to the instructions and regularly. Even so, 0.05-0.3% of women did become pregnant.

And this is an excellent result. In comparison, the proportion of women who became pregnant while using the male condom was 2%.Sperm-killing vaginal suppositories and gels failed the owners in 18% of cases, and vaginal diaphragms, which were used together with gels, in 6% of cases.

As with any drugs, hormonal contraceptives have side effects, but the benefits from them in most cases far outweigh the harm. For example, birth control pills were recently found to protect women from ovarian and endometrial cancer.

It is interesting that even a complete “abolition of menstruation” does not harm the female body.It is even helpful – if a woman suffered from endometriosis before taking contraceptives, hormonal contraceptives can help relieve symptoms.

But for contraception to be useful, an important condition must be observed: the drug must be selected correctly. This should be done by a doctor.

No. For most women, the ability to have children is restored in the first month after giving up hormonal contraception.

The only exception is injectable methods of contraception, which last for 3-6 months.In order for the probability of conception to be higher, it is worth waiting 6-10 months from the moment of the last injection.

Hormonal contraceptives are divided into two large groups: progestin and combined, the latter include progestins and estrogens. Although drugs from both groups prevent pregnancy, they work slightly differently and have different side effects.

For example, in addition to protecting against unplanned pregnancy, combination drugs treat acne and reduce menstrual pain – but more often progestin-only drugs cause headaches, and they should not be smoked.

In addition, the difference in composition allows you to select a contraceptive for the needs of a particular woman. The medication a teenager needs may be different from a 40-year-old mother of two.

What they are. Progestin-only contraceptives come in the form of tablets, subcutaneous implants, and injections.

Suitable for anyone. A universal remedy, suitable for almost everyone. Most often it is recommended for patients who have contraindications for combined contraceptives: nursing mothers and women who have contraindications for taking combined contraceptives.

Frequent side effects. Acne, breast tenderness, headaches. Sometimes spotting occurs, or these contraceptives lead to a complete absence of menstruation, which does not suit everyone.


    If a woman chose pills, and more than 5 days have passed since the last menstrual period, 2 more days after taking the first pill, you need to use additional methods of contraception. If less than 5 days have passed, additional contraception is not needed.

    If a woman does not have a menstrual cycle and is not pregnant, you can start drinking the drug on any day of the cycle. Just in case, you need to use additional means of protection for another 2 days.

    The tablets can be taken immediately after the baby is born, but it is better to start one month after the birth. So there is less danger of thromboembolism – blockage of a vein by a blood clot.

    If a woman has chosen an injection or an implant, and more than 7 days have passed since the last menstrual period, additional means of protection should be used for another week.If less than 7 days have passed, additional contraception is not needed.

    How to take. You can start taking the pills any day of your cycle. Stop taking – too, “finishing” the package to the end is not necessary.


    • Suitable for women of any age
    • Suitable for women who have given birth and have not given birth
    • Before taking the drug, you do not need to be examined by a gynecologist


    • Must be taken every day

    905 How to use.Under local anesthesia, it is injected under the skin once every 3 years on any day of the cycle. You can retrieve it at any time.


    • The most reliable method (less than 0.5 pregnancies per 100 women per year of use)
    • The maximum possible period for hormonal contraceptives is valid: 3 years
    • Suitable for both women who have given birth and who have not given birth
    • Reduce the number of menstrual flow


    • Painful sensations may occur when installing and removing the implant

    How to use.Depending on the drug, once every 2-3 months on any day of the cycle, an injection is made into the gluteus muscle or deltoid muscle of the shoulder.


    • Convenient compared to pills: you need to think about contraception only once every 2-3 months
    • Suitable for women of any age
    • Suitable for women who have given birth and have not given birth


    • Injection can be painful, sometimes bruises and bumps appear
    • Side effects are more often expressed: acne, increased hair growth (hirsutism)

    What are.Combined contraceptives come in the form of pills, vaginal rings, and patches.

    Suitable for anyone. Most healthy non-smoking women before menopause. However, all people (and drugs) are different, so you need to select pills together with a gynecologist.

    Who do not fit. Nursing mothers, women over 35 who smoke more than 15 cigarettes a day, and women suffering from cardiovascular diseases, cancer, bleeding disorders, migraine with aura, complicated diabetes and liver disease.


    Before prescribing a combined contraceptive, the doctor should ask the patient about her well-being in detail and measure blood pressure. The drug is not suitable for women with arterial hypertension. If the pressure is below 140/90 mm Hg. Art., the medicine can be used.

    If more than 5 days have passed since the last menstrual period, in order not to get pregnant, you need to use additional methods of contraception for another week. If less than 5 days have passed since your last menstrual period, additional contraception is not needed.If a woman does not have a menstrual cycle, and she is not pregnant, you can start drinking the drug on any day of the cycle. Just in case, you need to use additional methods of contraception for another week.

    Combined contraceptives are not recommended for the first 3-6 weeks after childbirth. This will reduce the risk of thromboembolism.

    How to take. The tablets should be taken one piece a day at the same time. If you miss even one day, there is a small risk of getting pregnant.

    Most of the modern combination drugs are 21 tablets, after which the woman does not take the drug for 7 days, or 24 tablets with the active ingredient and 4 “pacifiers” without the active ingredient. These pills are more convenient because they can be taken continuously.


    • Help to normalize the cycle for women with irregular periods
    • Reduce menstrual flow by 40-50%
    • Reduce menstrual pain in 70-80% of patients
    • Can be used to treat acne
    • Reduce blood loss and pain myoma and endometriosis
    • Reduces the risk of certain cancers (ovarian cancer, endometrial cancer and colorectal cancer)
    • Strengthens bones


    • Must be taken every day at the same time
    • Not recommended for breastfeeding mothers
    • Not suitable for everyone: there are contraindications

    • Side effects: from spotting in the first month of admission to headaches and depression

    How to use.Insert into the vagina once a month, like a tampon. After 3 weeks, the ring must be removed, and a weekly break should be taken. After a week, insert a new ring.


    • All the advantages of pills, but the ring is more convenient to use
    • Compared to a patch: invisible on the body


    • Can be felt inside the vagina
    • May fall out – then it needs to be rinsed under running water and insert again
    • The risk of vaginal microflora disorders increases, symptoms may increase in people with vaginosis and candidiasis
    • May interfere with intercourse

    How to use.Stick on belly, thigh or shoulder. The patch should be changed once a week. After three weeks, take a break for one week.

    • All the advantages of pills, but the plaster is more convenient to use
    • Compared with a vaginal ring: no problems with discomfort and vaginal microflora


    It gets dirty quickly and does not look aesthetically pleasing – Can often come off, especially in summer – More often needs to be replaced than a ring – May cause irritation on the skin – Few options: it is difficult to find an alternative patch if it causes side effects

    If a woman has a regular cycle, and contraceptives are needed only so that an unplanned pregnancy does not occur, have sex tests hormones, biochemistry and blood clotting are not necessary.

    If a woman has had health problems, the doctor may prescribe additional tests. This will help ensure that the contraceptive method you choose will do more good than harm.

    If the absence of menstruation does not bother you, you do not need to cancel hormonal contraceptives, it will not harm your health, and will not affect your ability to have children in the future.

    To avoid your period, you can use birth control pills continuously. And if you put in an implant or regularly inject, there is a chance that your periods will go away on their own.

    Contraceptives with progestins: tablets. If you remember about a missed pill within 3 hours, just drink it and continue taking as usual. Two days after that, you will have to additionally protect yourself.

    If you remembered the pill later, the recommendations will be the same. The only problem is that the reliability of contraception in this situation is a big question. If you forget about pills all the time, you may be better off with another method of contraception. Contraceptives with progestins: injections.If you are less than 2 weeks late with the injection, just give it – no additional contraceptive measures are needed. If longer – too. The main thing is to make sure that you are not pregnant, and additionally use protection for a week.

    Combined contraceptives: tablets. If you remember about a missed pill within two days, just take it, and then continue taking the pills “on schedule.” It’s okay if you have to take two tablets in one day. In addition, you do not need to protect yourself.

    If more than two days have passed, you only need to take the last missed pill, and then drink on schedule. True, in this case, you will have to use additional methods of contraception for a week – for example, a condom.

    The risk of getting pregnant depends on which pill you forget about. If this happens at the beginning or at the end of taking the tablets with the active substance, the chance of getting pregnant is higher. In this situation, it is worth consulting with your doctor and insuring yourself, even if less than 2 days have passed.

    Combined contraceptives: ring, plaster. If less than two days have passed, simply insert a new ring or apply a patch. Additional protection is not necessary. If more than 2 days have passed, use a contraceptive and additionally protect yourself for a week. It is worth talking to your doctor: if you have had unprotected contacts, you may need emergency methods of contraception.

    In this situation, doctors advise you to just take another pill – regardless of which contraceptive you used.If nausea and diarrhea persist for more than two days, act as if you missed a pill.

    Side effects did not go away within 2-3 months from the start of the contraceptive intake. If the bloody discharge and nausea persist, you need to see a doctor to change the drug.

    Feels bitter in the mouth, severe dizziness and bleeding. These symptoms persist over time. If they appear, you should immediately consult a doctor to change the drug.

    • Correctly selected method of hormonal contraception is a reliable and safe way to avoid unplanned pregnancy.
    • Hormonal contraceptives have contraindications, limitations and side effects. You need to choose a contraceptive together with your doctor.
    • If the absence of menstruation does not bother you, it is not necessary to take a break from taking contraceptives. To maintain health, there is no need to endure menstruation.
    • If the side effects of contraceptives do not go away within 2-3 months, you need to see your doctor to help you choose the most suitable contraceptive.


    Tell your doctor if you are using, have recently taken or might be taking any other medicines.The following drugs are especially important:

    If necessary, your doctor will reduce the dose of these drugs before using lorazepam.

    Avoid drinking alcohol while taking lorazepam as it may increase the sedative properties of the medication.

    Tell your doctor or pharmacist if you are taking Lorazepam before using any other drugs or in hospital treatment.

    Some elderly patients may experience dizziness and fainting after taking Lorazepam.

    When taking Lorazepam, there is a risk of habituation, which can lead to a gradual decrease in effectiveness after several weeks of taking Lorazepam.

    Lorazepam has the potential to develop dependence, particularly in patients with a history of alcohol and / or recreational drug abuse.

    With the usual regimen of lorazepam, the development of dependence is unlikely, but the risk increases with increasing doses and increasing duration of treatment, as well as in patients with a history of alcohol and / or recreational drug abuse or in patients with personality disorder.Therefore, lorazepam should be avoided in patients with a history of alcohol and / or recreational drug abuse.

    Addiction can lead to the development of a withdrawal syndrome, especially with sudden discontinuation of treatment. Therefore, it is necessary to carry out the withdrawal of the drug gradually.

    When taking lorazepam for more than 4 weeks, your doctor should conduct a peripheral blood test, as well as a biochemical blood test for liver markers, as drugs in this group can lead to liver dysfunction.

    Long-term use of Lorazepam can lead to the development of drug dependence. Therefore, Lorazepam is usually prescribed in short courses lasting from several days to 4 weeks, including a period of dose reduction and drug withdrawal. This reduces the risk of drug dependence or adverse side effects observed when the drug is discontinued. (See Section “Cancellation of Lorazepam”).

    The dose of Lorazepam should be increased gradually to avoid the development of side effects.

    The evening dose should be higher than the daily dose of the drug.

    How to take Lorazepam

    Lorazepam should be taken exactly as directed by your doctor. If you have any doubts, then you should consult with your doctor.

    When using Lorazepam for the treatment of anxiety and insomnia, treatment usually lasts from several days to 4 weeks, including a period of dose reduction and drug withdrawal.

    The doctor should prescribe the lowest effective dose, calculated for the shortest possible period of taking the drug.

    Lorazepam tablets must be swallowed with water.

    Adults and children over 13 years old

    In case of anxiety, the daily dose of Lorazepam is 1-4 mg, taken in divided doses. Your health care provider will determine how often you take Lorazepam. Lorazepam is not recommended for children under 12 years of age with anxiety.

    For disorders of the patient, 1-2 mg of Lorazepam are prescribed at bedtime. Before taking the drug, you must be sure that you can get 7-8 hours of sleep.

    2-3 mg Lorazepam is prescribed at night before surgery and 2-4 mg 1-2 hours before surgery.

    Children from 5 to 13 years old

    For surgery, the dose is usually 0.5-2.5 mg (depending on your child’s weight) taken one hour before the procedure.

    It is not recommended to use Lorazepam in children from 5 to 13 years old for the treatment of anxiety and sleep disorders, as well as in children under the age of 5 years.

    Old age

    The physician should prescribe Lorazepam to elderly or malnourished patients at low doses.

    The drug may be effective when taken at half or even less of the recommended dose in elderly patients, however, if necessary, the dose should be adjusted.

    Patients with renal and hepatic impairment

    In case of impaired renal function or mild to moderate hepatic impairment, it is allowed to take Lorazepam only in low doses.

    Lorazepam is contraindicated in patients with severe hepatic impairment.

    If you forget to take Lorazepam

    If you forget to take Lorazepam for anxiety and if less than 3 hours have passed since the scheduled time of admission, you should take it as soon as you remember. If more than 3 hours have passed since the appointed time, do not worry, take the next dose at the appointed time. Do not take a double dose to make up for the missed dose.

    If you forget to take Lorazepam to treat your sleep disorder, take it if you are sure you can sleep 7-8 hours after taking the drug.

    If you have used more Lorazepam than recommended

    If you have taken more Lorazepam than prescribed by your doctor, seek immediate medical attention, call your doctor, or go to the nearest hospital. Take the package of the medicine with you, even if there are no pills left.

    Cancellation of Lorazepam

    After completing the prescribed course of treatment, your attending physician will decide on the extension of further treatment.

    The dose and frequency of Lorazepam should be reduced gradually until the drug is discontinued. This allows your body to adjust to the absence of Lorazepam and reduce the risk of adverse effects if the drug is discontinued. Your doctor will tell you how to do this.

    If you have any further questions on the use of this medicine, ask your doctor or pharmacist.

    Withdrawal syndrome

    If Lorazepam is suddenly stopped, withdrawal symptoms may occur, such as headaches, muscle aches, anxiety, tension, depression, anxiety, dizziness, nausea, diarrhea, loss of appetite, confusion, irritability, agitation, tremors, abdominal pain, heart rhythm disturbances , short-term memory loss, fever and sweating.A relapse of insomnia is possible. If you have any of these symptoms, see your doctor.

    Do not stop taking Lorazepam suddenly. This can lead to more serious withdrawal symptoms, such as loss of a sense of reality, feeling unreality of what is happening or being disconnected from everyday life, and loss of the ability to feel emotions.

    Some patients experience numbness or tingling of the hands or feet, vomiting, ringing in the ears, muscle twitching, hallucinations, convulsions, and increased sensitivity to light, sound and touch.If you have any of these symptoms, see your doctor immediately.

    90,000 Pfizer Vaccination – How Long Does Immunity Last, Study Findings

    The effectiveness of Pfizer’s COVID-19 vaccine will drop 90,095 to about 84% 90,096 4-6 months after the second dose. The initial efficiency is stated at 96.2%.

    This was announced by Pfizer CEO Albert Burla on the air of CNBC. The data is based on a new company-funded study that has yet to be peer reviewed, he said.

    More than 44 thousand vaccinated volunteers took part in the study.

    Earlier, the manufacturer clashed with US health officials, who insisted on the need for a third dose of the vaccine to increase immunity protection.

    Video of the Day

    It is noted that if the effectiveness of the Pfizer vaccine declines at the same rate over time, then within 18 months from the date of vaccination, the effectiveness of the drug will be less than 50%. In this case, revaccination will be necessary.

    Recall that the main component of the Pfizer vaccine is a messenger RNA molecule, which contains information about an antigen – a protein of the SARS-CoV-2 virus, which is the causative agent of COVID-19. When this molecule enters the human cell, this protein is synthesized there, and our body produces an immune response to it. Such vaccines are called RNA vaccines.

    Like most other types of vaccines, it cannot cause the disease it protects against because it does not contain viral particles and they are not used in the vaccine production process.In addition, it cannot even theoretically affect the human genome.

    There is a small chance that the Pfizer vaccine could cause a severe allergic reaction. It usually occurs within minutes to one hour after a dose of the drug is administered.

    Signs of a severe allergic reaction may include:

    • shortness of breath,

    • swelling of the face and throat,

    • heart palpitations,

      • weakness.

      As reported by OBOZREVATEL, a longer interval between the first and second doses of Pfizer vaccine causes the body’s immune system to produce more antibodies that fight the coronavirus. Therefore, an eight-week break is better than an interval of three weeks, as previously thought.

      When, how much and how to drink water: whether to count other drinks and soups as drinking water – Lifestyle – News of St. Petersburg

      The “two-liter” myth is beneficial only for beverage producers – it has a great effect on sales Photo: Leonid Menshenin / 74.RUShare

      The myth that a person needs to drink at least two liters of water a day has not been so many years, but all of humanity willingly believes in it. Together with nutritionists, we figured out how much liquid a person actually needs and whether only water is considered it. Maybe soup would work too?

      Where did the two-liter rule come from?

      Experts agree that the two-liter rule first appeared in 1945 when the American Nutrition Commission issued a recommendation that “the average adult needs about two and a half liters of water a day.”True, it was also said there that a person receives part of the necessary liquid from food, but apparently not everyone had read this remark before or simply ignored it. Nutritionist Margaret McWilliams later wrote in her book Nutrition for Good Health that a person needs to drink six to eight glasses of water a day, again adjusted for other drinks, fruits and vegetables. But in the collective consciousness, only information about the number of glasses was again entrenched.

      How much should you actually drink?

      There are countless formulas used to calculate fluid intake rates.One of the most famous says that you need to multiply 30–45 ml of water per kilogram of body weight. But this is how the volume of the required liquid is calculated. And it doesn’t have to be water. In fact, everything is much simpler.

      “A person’s need for fluid and water depends on many parameters – gender, age, weight, physical activity, climatic conditions – and differs in different circumstances,” says Veronika Cheraneva, a gastroenterologist and nutritionist at the New Hospital. – A healthy person does not need to calculate the norms of water consumption, since the mechanism of water exchange in the body is regulated according to the principle of feedback with the help of a feeling of thirst.According to modern recommendations, drinking water when you feel thirsty, that is, on demand, is enough to maintain the water-electrolyte balance. If the feeling of thirst is dull or there are chronic diseases that require correction of the consumed volume of fluid, then in these cases its amount is calculated individually by a specialist.

      Veronika Cheraneva – gastroenterologist, nutritionist. Specialist in the treatment of gastric ulcer and duodenal ulcer, gastritis, pancreatitis, cholecystitis, dysbiosis, flatulence, colitis, constipation, esophagitis and other diseases of the gastrointestinal tract.

      Can coffee, soup or tea replace water?

      The fact of the matter is that nutritionists mean almost everything by liquid. This includes fruits, vegetables, soups, and milk. Cucumber, for example, is 95% water, and iceberg lettuce is 98%.

      – The total consumption of liquid includes not only water, but also soup, tea, compote, coffee, kvass, kefir, liquid of vegetables and fruits and that which we get with food; for example, cottage cheese contains up to 70% water, says Veronika Cheraneva.

      The only thing nutritionists pay attention to is that it is still best to replenish fluid in the body with water, because there are no calories and additives in it. Unlike various juices, fruit drinks, smoothies and other drinks, water is as inert as possible and does not affect the stomach. And any liquid that contains sugar, fiber or extractives stimulates the production of gastric juice.

      Replenish fluid to stay hydratedPolina Avdoshina / City Portal NetworkShare

      Plain water or mineral water?

      – Mineral water is not potable.Drinking it in liters is not useful. For those who want to improve the work of digestion (for example, the choleretic effect is pronounced), then it is drunk half an hour before meals in a warm form. For everyone else – after eating, and not immediately, but after half an hour or an hour, in small sips, without haste, – says nutritionist Galina Bartashevich.

      Galina Bartashevich – gastroenterologist of the highest category, pediatric gastroenterologist, nutritionist, Ph.D., work experience – more than 30 years.

      Mineral water refreshes, stimulates appetite and helps relieve fatigue, but table water with a degree of mineralization of no more than 1 g / l, as well as medical-table water with a mineralization of 4–5 g / l, are suitable for this.At the same time, you can drink a glass of water no more than 200 ml at a time. Otherwise, you will get an extra burden on the kidneys and heart. Most often, the level of mineralization is indicated on the package. And to make it easier for you to classify water, take a look at a special table.

      How to distinguish mineral water by mineralizationVitaliy Kalistratov / Network of city portalsExcess mineral salts can negatively affect patients with kidney disease, cardiovascular disease, accompanied by edema and high blood pressure. Regular consumption of mineral water with a low content of fluoride contributes to the development of fluorosis, can cause impaired bone strength and the occurrence of caries. At the same time, a large amount of fluoride interferes with the functioning of the body.

      It is generally interesting to look at the chemical composition of mineral water. There are even toxic elements there.Therefore, the wrongly chosen mineral medicinal table water will not only not provide the body with the necessary microelements, but will also noticeably worsen the state of health.

      Large quantities of mineral water can be toxicVitaly Kalistratov / City Portal NetworkShare

      What happens if you drink too much water?

      – With an excessive and rapid flow of water into the body, the balance of electrolytes is disturbed: the level of sodium in the bloodstream decreases, and water goes into the cells, causing them to swell, says Veronika Cheraneva.- This condition is accompanied by weakness, nausea, dizziness, in severe cases, convulsions and cerebral edema develop.

      But here it is also important to consider under what conditions you drank too much water: two liters in one sitting or during the day. If you just slightly exceed the daily allowance (and you have no contraindications in terms of health), the water will come out naturally.

      By the way, the fact that an extra couple of liters of water a day flushes out toxins or stimulates the kidneys is nothing more than a myth.In one study, scientists collected 631 patients with kidney disease and divided them into two groups. The first drank more water than usual, the second was the control. At the end of the experiment, the doctors found no difference in the condition of the patients. Other researchers came to the same results when they performed an experiment on 141 elderly men.

      Cases of water overdose are known but very rare. To make problems, you need to drink at least five to six liters of water in one sitting.This can actually drastically reduce blood sodium levels, lead to brain and lung edema, and all could end in death.

      Should you start your day with a glass of water?

      The habit of drinking water in the morning on an empty stomach is considered insanely beneficial, but in fact it can even lead to cancer. It’s all about the temperature. It is not recommended to drink cold water on an empty stomach if you have problems with the stomach and cardiovascular system. Too hot water (with a temperature above 65 degrees, but you hardly measure it every time), if you drink it regularly, damages the lining of the esophagus, and too frequent burns will cause more and more abnormal cells to appear, which can eventually become malignant.

      The benefits of warm water for the bodyVitaliy Kalistratov / Network of city portals

      “You should drink only warm water, because cold water, on the contrary, can provoke an increase in appetite,” says Irina Borodina. – Or green tea. It actually suppresses appetite for some, fills the stomach. The receptors tell the brain that there is something in the stomach, and it can kill the appetite.But it is better not to drink coffee on an empty stomach. Often, on the contrary, it provokes a surge in appetite. Therefore, many who skip breakfast and get by with a cup of coffee, then during the day want to eat all the time.

      Irina Borodina – nutritionist of the Yekaterinburg City Center for Medical Prevention, Candidate of Science, 1st category therapist.

      Who is recommended to use more water?

      “Controlling fluid intake is important for the elderly and in mental illness, when the feeling of thirst is disturbed,” says Veronika Cheraneva.- These people are advised to drink regularly throughout the day and monitor the color of urine, it should be light yellow. It is recommended to increase the amount of liquid with a tendency to constipation, with urolithiasis. During intense physical exertion and in professional sports, uncontrolled intake of large amounts of water is dangerous due to electrolyte disturbances, therefore, athletes and people engaged in hard physical labor are advised to replenish losses with the help of water-electrolyte mixtures with sodium content in the composition.

      The more water, the more beautiful the skin?

      First of all, you need to learn to distinguish between dry and dehydrated skin. The first case indicates a lack of lipids, the second – a lack of water in the cells of the upper layer of the skin. Any skin can be more dehydrated: dry, normal, and even oily. Yes, the lack of moisture is harmful to the skin, but this does not mean that the skin will look younger if you start drinking more water.

      If dehydration continues long enough, the tissues of the body begin to dry out, and the cells shrink and their function is disrupted Infographics: Polina Avdoshina / City Portal Network Share

      – Reliable scientific evidence that water makes our skin more beautiful, as well as that it slows down aging, no, says Veronica Cheraneva.