Why I Typically Don’t Use Brandt’s Habituation Exercises for BPPV

McKenzie DiStefano PT/DPT

Overview of Brandt-Daroff Exercises

Benign Paroxysmal Positional Vertigo (BPPV) is a common vestibular disorder that causes sudden episodes of dizziness and vertigo. One treatment that often comes up is the Brandt-Daroff exercise, a set of habituation exercises aimed at reducing vertigo symptoms. While these exercises are a well-known recommendation, I prefer other treatment options for my patients for several reasons. Let’s take a closer look at Brandt-Daroff exercises, how they work, and why I generally recommend different approaches for treating BPPV.

What Are Brandt-Daroff Exercises?

Brandt-Daroff exercises are designed to help manage the symptoms of BPPV by promoting habituation—the process through which the brain becomes less sensitive to the motions that trigger dizziness. These exercises involve moving the head into specific positions that provoke vertigo, and through repetition, the brain learns to adapt and ignore these sensations. Brandt-Daroff exercises allow patients to perform them at home, giving them a sense of control over their condition.

Execution and Frequency

The Brandt-Daroff exercises are simple and easy to follow, typically consisting of the following steps:

1. Sit Up: Begin by sitting on the edge of a bed or couch.
2. Lie Down Quickly: Lie down quickly onto one side (e.g., left side), keeping your nose pointed up at a 45-degree angle.
3. Stay Put: Hold this position for about 30 seconds or until the dizziness passes.
4. Return to Sitting: Sit back up and wait for 30 seconds.
5. Repeat Other Side: Perform the same exercise on the opposite side (right side).

These exercises are typically repeated 5 times per session, 2-3 times a day. While it can feel uncomfortable at first, consistency is key, and many patients experience a reduction in dizziness after several weeks of practice.

How Brandt-Daroff Exercises Work: Habituation and Adaptation

The goal of Brandt-Daroff exercises is to habituate the brain to the motions that provoke dizziness by repeatedly exposing it to these movements. Habituation is the process where the brain learns to ignore a stimulus after repeated exposure, allowing it to reduce the intensity of the dizziness response over time.

Neuroplasticity and Adaptation

The brain is incredibly adaptable through a process called neuroplasticity—the brain’s ability to reorganize itself by forming new neural connections in response to learning and experiences. As patients perform these exercises, their vestibular system is exposed to the movements that usually cause dizziness. Over time, the brain adapts and learns that these movements are not dangerous, ultimately reducing the dizziness response.

Reducing Dizziness

The repeated practice of the Brandt-Daroff exercises helps “train” the brain not to overreact to the movements that trigger vertigo. Although initially unsettling, these exercises promote neuroplastic changes, leading to less sensitivity to certain head movements. With persistence, patients often notice a gradual reduction in dizziness frequency and intensity.

Why I Don’t Use Brandt-Daroff Exercises for BPPV as First-Line Treatment

Despite being a commonly recommended treatment, Brandt-Daroff exercises are not my first choice for managing BPPV. Here are the key reasons why I generally prefer other, more targeted interventions:

1. Lack of Specificity

While Brandt-Daroff exercises are useful for habituation, they do not address the underlying cause of BPPV—the displaced calcium crystals (otoconia) in the inner ear. In contrast, canalith repositioning maneuvers, such as the Epley maneuver, are specifically designed to move the otoconia out of the semicircular canals, directly addressing the root cause of BPPV. These maneuvers typically provide faster and more effective relief.

2. Longer Treatment Duration

Brandt-Daroff exercises require several weeks of consistent practice to achieve results. This can be a challenge for patients looking for quick relief. Canalith repositioning maneuvers, on the other hand, can often resolve the symptoms of BPPV in just one or two sessions with a trained provider, providing faster results for patients.

3. Potential for Recurrence

Although Brandt-Daroff exercises can help reduce symptoms, they do not directly fix the issue of displaced otoconia. Therefore, there is a higher chance of recurrence of BPPV in the future. Canalith repositioning maneuvers, which specifically target the dislodged crystals, have been shown to have higher success rates and lower recurrence rates compared to Brandt-Daroff exercises.

4. Patient Compliance

Brandt-Daroff exercises require patients to perform multiple sessions a day, which can be difficult to maintain consistently. This can be especially challenging for patients who have difficulty following through with home exercises. In contrast, canalith repositioning maneuvers typically require only one or two visits to a healthcare provider, making them easier for many patients to comply with.

5. Research Support

The evidence base for canalith repositioning maneuvers is strong, with studies showing high success rates for treating BPPV. While Brandt-Daroff exercises are effective for some patients, they are often considered a secondary option when repositioning maneuvers are not feasible or practical. Research overwhelmingly supports the use of repositioning maneuvers as the first-line treatment for BPPV due to their faster results and higher success rates.

Conclusion

Brandt-Daroff exercises can be a helpful tool for managing BPPV, particularly for patients who need a self-care option or when repositioning maneuvers aren’t available. However, I prefer to prioritize canalith repositioning maneuvers due to their direct targeting of the root cause of BPPV and their faster, more effective results. For patients who need further help after repositioning maneuvers, Brandt-Daroff exercises can be useful for continued management, but they are not the primary treatment for this condition.

---

References:

1. Hain, T., & Roberts, R. (2008). Benign paroxysmal positional vertigo. Seminars in Neurology, 28(2), 146-157.
2. McCluskey, L., & Hain, T. (2003). Canalith repositioning for benign paroxysmal positional vertigo: A review of the literature. Journal of Vestibular Research, 13(5), 321-332.
3. Parnes, L. S., & McCluskey, L. (2003). Benign paroxysmal positional vertigo: Diagnosis and management. The Laryngoscope, 113(5), 858-864.