Vestibular First

Have you seen bilateral BPPV after traumatic brain injury (TBI)? In one study 34% of patients with acute moderate-to-severe TBI developed BPPV, and 39.6% of those cases were bilateral (Smith et al., 2024). ?? Unlike idiopathic BPPV, post-traumatic cases often involve multiple canals, persist longer, and require more treatments. This 58 year old female experienced a fall while headed to the bathroom at night, hit her head, and was taken to the emergency department. They sent her home after ruling out a brain bleed. She presented to outpatient PT evaluation 1 week later, and we found bilateral posterior canal BPPV. If it hadn’t been identified and treated, her risk for another fall would be very high! Infrared video goggles are essential in these cases—without the ability to remove fixation and record, it is easy to misinterpret direction of nystagmus or mistake central for peripheral nystagmus, leading to a missed or inaccurate diagnosis. For patients with TBI who may not even feel dizzy, identifying and treating BPPV early can significantly improve recovery outcomes. v1st.co/BSee25 to register for upcoming Journal Club on BPPV after TBI. Smith RM, Burgess C, Beattie J, Newdick A, Tahtis V, Sahu B, Golding JF, Marsden J, Seemungal BM. Treating benign paroxysmal positional vertigo in acute traumatic brain injury: a prospective, randomised clinical trial assessing safety, feasibility, and efficacy. BMJ Neurol Open. 2024 May 28;6(1):e000598. doi: 10.1136/bmjno-2023-000598. PMID: 38818242; PMCID: PMC11138307. #concussionrehab #tbi #bppv #vestibularrehabilitation #neuropt

Got a tough apogeotropic horizontal canal BPPV case? Try the Square Wave Maneuver! Step-by-Step Protocol (Please note that the clinician supports the patient’s head in a true patient case; this is a quick demo): 1. Patient begins supine with head elevated 20-30° resting on your hands 2. Rotate head and body 90° en bloc to one side while monitoring nystagmus 3. Once nystagmus reaches maximum intensity, quickly rotate patient 180° en bloc to opposite side 4. After nystagmus reverses and reaches peak intensity, rotate 180° again 5. Repeat up to 10 cycles until apogeotropic converts to geotropic positional nystagmus or nystagmus resolves Clinical Evidence: 93% success rate in single-session treatment (14/15 patients, Yacovino et al. 2021). Minimizes neck discomfort since no cervical rotation is required. Key advantage: No need to identify the affected side before treatment, making this ideal for difficult diagnostic cases! v1st.co/BSee25 to register for our upcoming Journal Club on BPPV. Post created in collaboration with Sonia Vovan, PT (@allinyourheadpt). #VestibularRehabilitation #BPPV #VestibularTherapy #PositionalVertigo Sonia Vovan Barry Seemungal PhD FRCP

What's your favorite effective option for treatment of posterior cupulolithiasis? v1st.co/NeuroCog for a free 1.5 hour on-demand course on neuroplasticity of cognition in patients with various neurologic and vestibular conditions. #bppv #vestibularrehabilitation

Great to be at Denver with the awesome @ptpintcast, @blazepod, and @fyzicalshavanopark amongst others for the @fyzical_therapy_and_balance conference. v1st.co/events to see where you can meet up with us next! #vestibularrehabilitation #balance Gaylord Hotels Helena Esmonde, PT, DPT, NCS Jimmy McKay PT, DPT Brian Werner, PT, MPT, Cert. MBR-L3, Cert. BPPV Allie G.

This person's eyes are demonstrating a normal physiologic response to rotation, showing that each vestibular apparatus is firing when stimulated. Which canal is primarily activated with rotation in the demonstration? Answer in the poll! #vestibularrehabilitation FYZICAL Therapy & Balance Centers

This person's eyes are demonstrating a normal physiologic response to rotation, showing that each vestibular apparatus is firing when stimulated. Which canal is primarily activated with rotation in the demonstration - posterior, horizontal, or anterior? #vestibularrehabilitation FYZICAL Therapy & Balance Centers

Have you seen a person with vestibular epilepsy? Frequency of early seizures after severe head injuries is often higher (10%–15% adults; 30%–35% children - Ding et al., 2016). v1st.co/BSee25 to register for our Journal Club on BPPV after Brain Injury. #bppv #epilepsy

??Life goal achieved: teaching at the Denmark Physiotherapist Association conference was amazing! I’m filled with gratitude for the incredible support I received there. 100 people on a wait list for the 80 person mini-class! I always learn as much as I share when I teach, and I made wonderful friends for life. Can’t wait to go back someday! #denmark #vestibularfirst Bodil Tilma

Ready for ?? vestibular updates? v1st.co/VS2025 to enter to win a free ticket to the Midwest Vestibular Symposium in Chicagoland (1 day of awesome speakers with latest updates on vestibular topics). It's an in-person-only event not to be missed! #vestibularrehabilitation

Would you send this person immediately to the emergency department (ED)? Here’s why I did: This 84 year old male was seen previously on two separate occasions over the last 3 years for classic posterior canal BPPV that resolved with canalith repositioning maneuvers. He returned to vestibular therapy with complaints of positional vertigo, but his presentation was concerning. Some red flags (when taken all together): ??persistent downbeat nystagmus throughout positional testing that did not suppress with visual fixation light on in infrared video goggles; ??patient was not able to walk or stand independently - he arrived in a wheelchair despite being independent with mobility prior to this episode; ??patient demonstrated NEW right eye miosis (pupil constriction) and ptosis (eyelid drooping) – concerning for brainstem stroke; ?? age and extensive cardiovascular risk factors. These signs/symptoms warranted a referral to the ED for further evaluation. Per my recommendation, he was able to undergo a stroke workup quickly upon arrival. Interestingly, his initial head CT and brain MRI came back normal. But did you know that imaging can be unreliable in acute onset dizziness? ????CT has shown sensitivity as low as 7% for posterior fossa strokes who present to the emergency department; ????MRI is preferred over CT, but can miss acute infarctions (<48 hrs), especially in the posterior fossa. Upon re-test of MRI of the head hours later, this patient was found to have a posterior fossa stroke. What’s the takeaway message? Your bedside vestibular assessment skills may be MORE sensitive than early imaging in patients with acute onset dizziness! v1st.co/DizzyED for upcoming Dizziness in the ED courses, and v1st.co/BSee25 to register for a free April Journal Club on BPPV and Brain Injury. #vestibularrehabilitation #bppv #neurology Kerber K, Newman-Toker D. Misdiagnosing the dizzy patient: common pitfalls in clinical practice. Neurol Clin. 2015;33: 565-viii.