Vestibular First

04/29/2026

Happy National Pretzel Day (3 days late)!

04/29/2026

Save this post - it's a summary of BPPV maneuvers for each canal and type! Want to master BPPV beyond the Epley maneuver? v1st.co/NJ26 for a 2 hour continuing education $75 live-only webinar on Tuesday May 12, taught by our cofounder Helena Esmonde, PT. Bring your questions!

04/28/2026

🏎️🚞 Dizzy when a car moves in your peripheral vision or when watching a moving train? This is optokinetic flow, and it can be a real challenge for those with vestibular migraine, concussion history, or any other cause of visual motion sensitivity.

❎⭕ The activity here uses a very affordable tool: Hart charts. Often available as a free printable pdf online, a Hart chart is a piece of paper with rows and columns of alphabet letters that are NOT in alphabetical order (like a word search!).

📝Ⓜ️ Often there are two charts that are identical (or the letters may be arranged in a different order on the second chart for more challenge), except one has smaller sized letters than the other.

🅿️🅱️ One way to use a Hart chart involves the clinician calling out a letter on the chart with small-sized alphabet letters held near the patient. The patient finds that letter and then finds the same letter on the chart with larger sized letters - this chart is posted on a wall, on a TV screen, or held in the patient’s other hand.

🏁🚩 Add visual motion with a video playing an optokinetic video in the periphery, or with a video playing behind center vision, or with scarves being waved by the clinician in the periphery.

🎬🚦Cue the patient to focus on finding the letters and attending to their body (somatosensory) information while decreasing attention to the visual motion. Example: “Focus on finding the letter “L” as you press your feet firmly into the ground.”

🥅🥇The goal is to train the brain to prioritize certain sensory information instead of getting overwhelmed.

🏆🧰 Want tons more free vestibular rehab treatment ideas? Subscribe to our YouTube channel at https://www.youtube.com/!

04/27/2026

CANVAS - how do we diagnose it, and what treatment is available? Researchers are using the latest genetic science to develop medical treatments. In the meantime, vestibular rehab can be a worthy option. v1st.co/EP26 to register for a great update on VEMP testing!

04/24/2026

Are you a Vestibular Educator teaching in-person U.S. vestibular con ed courses in 2026-27? v1st.co/toolkit to sign up for our FREE loaner trainer toolkit for all your teaching needs. Props to Drs. Sara MacDowell and Sydney Duhe for yet another recent successful vestibular course! Dizzy Diagnostics

04/23/2026

👁️↔️ What does it mean - nystagmus that beats to the right with (not end-range) right gaze and to the left with (not end-range) left gaze?

🎯🧠 This is called “gaze-evoked direction-changing nystagmus,” and it can occur with a CENTRAL (brain) vestibular dysfunction.

🤔💭 So where is the brain dysfunction? Midline and lower parts of the cerebellum (such as the vermal pyramid, the uvula, the tonsil, parts of the biventer lobule, and the inferior semilunar lobule) and/or the brainstem (medulla or pons) may be affected in those with horizontal direction-changing gaze-evoked nystagmus.

💥 🦠 What causes cerebellar and/or brainstem lesions or problems? Possible root causes include stroke, multiple sclerosis, genetic or degenerative ataxias, vestibular migraine, or tumors, to name a few.

🩻🧪 Proper diagnosis requires a medical work-up that will likely include imaging (an MRI and/or MRA of the head and neck, for example), a full neurologic exam, and occasionally further testing such as a lumbar puncture, EEG, and/or genetic screening.

🚨🚑 If you see this as a vestibular clinician, particularly along with other unexplained central vestibular signs such as abnormal saccades, smooth pursuit, or VOR cancellation, refer the patient to a neurologist or other physician for work-up. If dizziness is acute and constant, send this patient to the ED!

🤯🌀 Also consider vestibular migraine criteria, since gaze-evoked direction-changing nystagmus can be present between and/or during vestibular migraine attacks.

😃 ❤️ Get your free resource on cerebellar stroke here: v1st.co/freestroke

(Citations: Baier and Dieterich, 2011; Lee and Kim, 2020; Bandini et al., 2025; Fratto et al., 2024; Li et al., 2023)

04/22/2026

💙 So important - neck pain can be a symptom of vestibular migraine as well.

Do you experience neck pain during or in between your migraine attacks? What helps? What hurts?

Neck pain is an extremely common symptom of . In fact, it is more common than nausea. It can occur during any phase of our attack- prodrome, aura, headache/ attack, postdrome, or interictal (between attacks.)

Most experts agree that neck pain is most commonly a symptom of a migraine attack, rather than a trigger. However, misdiagnosis is very common and many of us will spend so much time and money trying to fix the problem originating in our necks when it is really a problem originating in our brains.

Dr. Sandhya Kumar helps explain why neck pain occurs. “It makes sense that neck pain would be involved in migraine, because of the disease process in the body. The trigeminal nerve complex is involved in most [migraine attacks], and the nucleus (central part) of the trigeminal nerve is actually located high in the back of the neck, in what we call the c1, c2, and c3 vertebrae, the highest vertebrae in the spine. The trigeminal nerve is responsible for sensations in the face and for functions like chewing and biting. In migraine, those areas get sensitized; the muscles in the neck can become tense and tight.”

Dr. David Dodick explains, “I think it's important for patients to understand that where they experience pain may not reflect pathology underneath. The brain is what we call a visceral organ, it refers pain. So most people will have pain in this area or in the back of the head. It refers pain commonly, 80% to 90% of the time, to the neck. So oftentimes patients will [unnecessarily] get neck x-rays.”

Treating the migraine attack will help with the neck pain. And although the pain isn’t caused by the neck, methods such as occipital nerve blocks, heat, ice, physical therapy, massage, and other soothing methods may help relieve some of the pain. What works best for you?

04/22/2026

Does the Epley need an update? Try this modifications for stubborn cases and let us know how it goes! v1st.co/education to master BPPV with our continuing ed courses and v1st.co/epleyhandout for a free printable handout on the classic modified Epley! Balancing Act Rehab

04/21/2026

⚽🎾 Ready to work on tolerance to turns, dual task, and reaction time in vestibular or post-concussion rehab? Get out your physioball, playground ball, tennis ball, and ping pong ball!

⏰ 🦺 Remember to start with slow body/head movements, short duration repetitions (10-30 seconds), and scale to an easier activity altogether if you’re having a more symptomatic day. This exercise can also be modified to perform while seated or lying down.

🏋🏼‍♀️🧣Consider neck care and/or using weights (two-pound wrist weights or a weighted vest) to increase sensory input.

💊❓Can medication fix dizziness? Check out v1st.co/meds for a free resource with insights on this important topic!

📝🎯 Guidance from a trained vestibular clinician is recommended to ensure the correct challenge level and type of vestibular rehab activities for you individually. Research says an individualized program is the most effective vestibular rehab program!

04/20/2026

Do you see residual dizziness for your patients with successful BPPV treatment? Try the CLEAR Algorithm to reduce this issue! Ready to grow leadership skills? Attend the NABPT virtually or in-person in Atlanta this June! v1st.co/NA26 National Association of Black Physical Therapists NPTE Final Frontier

04/17/2026

Have you used the Kim maneuver for horizontal cupulolithiasis? It's a great option for those patients who cannot tolerate a brisk maneuver due to mobility issues, nausea, spinal pain, etc. v1st.co/freeKim for your free handout to remind you how it's done! Balancing Act Rehab