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With going to vestibular therapy courses have you found that learning how to treat BPPV affecting the anterior canal is often overlooked. This is understandable to some extent given that other vestibular conditions are more prevalent. Specifically with BPPV, according to Bhattacharyya, it only affects the anterior canal up to 3% of the time. Not nearly as common as the other two canals, where much of the training focuses on.

With that being said, BPPV affecting the anterior canal is rare, but it does happen. So, if you are treating patients with dizziness it is just a matter of time until you may see this form of BPPV. When you do it will be good to have a treatment technique up your...

Ever heard of Ewald's Laws?

If not, with assessing BPPV do you ever wonder why:

• With BPPV affecting the posterior canal, going into the Dix-Hallpike Test is more provocative than sitting up after?
• With BPPV affecting the lateral canal, going into the Supine Roll Test the side that is more provocative is not always the affected side?
• With cupulolithiasis affecting the lateral canal, the nystagmus beats towards the affected ear with the Lean Test?

Maybe you have not, but understanding the WHY behind these will help us treat the atypical forms of BPPV. It will also help us determine if there is another vestibular condition at play, mimicking BPPV.

What are Ewald’s...

A recent Instagram post caught my eye as it indicated that given a particular study, clinicians should not repeat positional testing after performing a canalith repositioning technique for BPPV. The reason for this, I believe, was due to the risk of causing the loose otoconia to fall right back into one of the canals.

To be honest this post surprised me. I just assumed that it was common practice now-a-days to repeat positional testing to see the effect of treatment. Don’t we want to evaluate the effect of our treatment? Then, when I went back to find that post and hopefully get the study they were referring to, it was buried deep in the social media abyss.

I was a bit disappointed...

BPPV is the most common cause of dizziness across the lifespan. Fortunately it is usually straight forward to treat. At times it can, however, be a bit tricky, especially if it involves the lateral canal. According to 2017 Clinical Practice Guideline for BPPV  5-15% of the time the lateral canal is involved. When the lateral canal is involved there are several treatment options. One of the newer ones being the Zuma maneuver.

Over the years I have become pretty comfortable treating lateral canal BPPV. I like using the BBQ Roll if canalithiasis is involved. If cupulolithiasis is involved I like using the Head Shake Maneuver. I will then follow it up with the BBQ Roll, if needed.

These...

Have you ever wondered about the relationship between drugs and oculomotor testing? From time to time I was curious, but never looked into it until I received an email a few months ago from Ocular Data Systems asking if I could work with them on a project to provide online lessons regarding vestibular physiology and how to analyze nystagmus findings for law enforcement officers, prosecutors, and toxicologists.

It seemed like a unique opportunity, a Canadian physical therapist helping educate law enforcement officers, prosecutors, and toxicologist from the USA. What I did not realize until then is that there is a group of very highly trained non-medical professionals who perform oculomotor...

I am not sure any of you watched the NFL game with the Bills and the Dolphins on Sunday September 25, 2022? If you did you would have seen the Dolphin’s QB Tagovailoa get pushed backwards, causing him to fall and hit his head on the turf. He was able to get up on his own. However, as he jogged across the field his legs looked like the scene of Bambi on the ice. If you missed it, here is a REPLAY.

With that, if you are like me, you were thinking that he was definitely going to be out for the rest of the football game. Then, the shocker came when he was allowed to resume play.

Did he sustain a concussion?

What are the signs and symptoms of a concussion?

Recognizing and evaluating...

Have you ever observed sustained (lasting > 60 sec) geotropic nystagmus with positional testing for BPPV and were not quite sure what those atypical findings were about? If so, you are not alone. According to the literature this finding is not as result of BPPV, but rather due to a light cupula which was first proposed by Hiruma in 2004.

My journey with experiencing a light cupula

Clinically, I actually do not remember ever seeing someone present with sustained geotropic nystagmus. If I did, the patient likely got better, not as a result of my treatment, but rather due to the natural history, which we will cover later in this post.

This past summer though, I released an online course...

If you are like us, you taken many vestibular therapy courses without being taught how to treat BPPV affecting the anterior canal. Granted, BPPV affecting the anterior canal is rare. If you, however, see a lot of patients with dizziness you will likely see this form of BPPV at some time. When that does occur what are your options?

• Search Dr. Google and hope for the best.
• Ask a colleague.
• Figure it out using an anatomical model (if you have one).
• Hope it will resolve spontaneously.
• Other.

Given such, let's review a treatment option that we have found simple and effective called the Deep Head Hang Maneuver. Before we review the technique let's review some background information.

How often...

If you follow the media, especially in regards to celebrities you may have heard that Canadian singer Justin Bieber was recently diagnosed with Ramsay Hunt and will have seen that his smile seems a bit off. He is not the only celebrity to develop a facial paralysis. Angelina Jolie, George Clooney, and Pierce Brosnan all developed facial paralysis, but they had Bell’s Palsy which is different than Ramsay Hunt and we will compare the two conditions below.

So, what exactly is Ramsay Hunt? Well, Ramsay Hunt or herpes zoster oticus is a neurological condition caused by a virus that affects the nerves on one side of the head. If someone has this condition, the two main findings...

Did you know that dizziness, headaches, and pain in the sinus region can be due to a binocular vision dysfunction (BVD)? There are several tests we can use to assess for this, but let's review one of the simplest being the 5 Minute Cover Test. Before we do this though, let's do a quick review of what a BVD is.

What is a binocular vision dysfunction (BVD)?

Binocular vision dysfunction is a condition where the eyes are not looking in the same direction. When looking straight ahead, to the side, up, down, as well as near and far the eyes should be aligned and move together as a pair. Causes of BVD are usually due to poor functioning of a nerve or nerves that control eye movement, or of the...