BPPV and Vitamin D

By Dr. Sean M. Wells, DPT, PT, OCS, ATC/L, CSCS, CNPT, Cert-DN

Vitamin D is a crucial nutrient that can be obtained from the sun and has seemingly endless roles in human health. Despite our ability to gain vitamin D from the sun, most Americans are deficient, perhaps due to improper or lacking sun exposure, dietary patterns, or other reasons. Supplementation is simple, effective, and has been shown to have positive impacts on not just our bones -- it can help muscle strength, balance, and even the immune system for some patients.

Yet another role for vitamin D may be in the prevention of benign paroxysmal positional vertigo, or BPPV. BPPV is one of the most common neuro-otological conditions DPTs see in clinical practice. BPPV can leave patients with a spinning sensation, inability to sleep, and balance or fall issues. Physical therapists commonly treat patients with BPPV using the evidenced based technique known as the Epley Maneuver. Other treatments include patient education regarding positioning, vestibular-ocular retraining exercises, and balance work. Should PTs start recommending patients to take vitamin D for BPPV also? Let's review the evidence!

Several studies from the 1990s started to highlight a correlation of vitamin D and vertigo. Some of these studies highlighted how patients with recurrent BPPV had lower vitamin D status. Building on this data, researchers in the 2000s started analyzing cohort and cross-sectional studies and finding some robust connections with vitamin D status and BPPV. Basically, the lower the vitamin D status, the higher the rate of BPPV recurrence.

The pinnacle of the data came in 2020 with a high-impact systematic review and meta-analysis. Researchers found that patients with low vitamin D status were more than twice as likely to develop BPPV again (WMD 2.59, 95% CI 0.35–4.82, p = 0.023)! Take a look at this forrest plot from the 2020 Yang et al study:

The data also show that those currently with BPPV are also likely deficient in vitamin D status. This systematic review and meta-analysis is one of the most comprehensive assessments of BPPV and vitamin D status in the last decade. Another review study was published a few years back and found similar findings, but failed to include many of the observational studies the current 2020 Yang et al article did. Overall, an assessment of 18 studies found a clear correlation with vitamin D and BPPV -- so, the question remains, why?

Mechanisms

Vitamin D helps the body absorb calcium. Most people understand that calcium is good for bone strength, but it is also crucial for anchoring the otoconia. When the free calcium concentration in internal lymphatic fluid is 20 μM, otoconia can dissolve completely; when the concentration is 500 μM, the crystals do not dissolve (Yang et al, 2020). Vitamin D can help maintain a sufficiently high free calcium concentration in the inner lymphatic fluid to prevent excessive dissolution of otoconia, likely thanks to its activation of transporter proteins that shuttle calcium from the utricle to the canals.

Many vestibular physical therapists know of the direct relationship between osteoporosis and BPPV. Deficiency in vitamin D can lead to calcium dissolution. This phenomenon not only happens in bone but may be occurring in or around the otoconia of the inner ear. In short, Vitamin D is essential for sustained inner ear functioning. So, other than self Epley's and X1 exercises, what should Doctors of Physical Therapy be recommending for their patients?

Recommendations

According to the American Physical Therapy Association, nutrition is in the scope of practice for PTs. Physical therapists should screen and educate patients on nutrition, depending on the PT's training and their relevant State laws. Given this position statement, at a minimum, Doctors of PTs can easily engage patients to ask a patient's primary care providers to recommend a specific dosage of vitamin D for their needs. Some PTs may simply recommend patients to take a standard supplement with 1,000 IUs per day, which can be found in most over-the-counter supplements. Afterall, most people need vitamin D and fall short of the vitamin. Lastly, some PTs may request a lab draw or use a at-home vitamin D status product, which can provide better guidance on how much Vitamin D a patient should take.

In the end, vitamin D can prevent BPPV and should be recommended for most patients. Physical therapists can help patients overcome BPPV, and possibly prevent future episodes, with good patient education focused on nutrition and Vitamin D status.

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