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As a healthcare provider, seeing patients with various medical conditions is part and parcel of our daily routine. However, there are certain conditions that are relatively rare, but require keen attention and understanding for effective management should they occur. One such condition is an acoustic neuroma, also known as vestibular schwannoma. In this blog, I will provide insights into what an acoustic neuroma is, its prevalence, clinical presentation, conservative treatment principles, and indications for surgery. Then, if you want to take a deeper dive, I'll provide some of my favourite resources at the end of the this blog. 

Understanding Acoustic Neuroma:

Acoustic neuroma is...

Do you ever struggle distinguishing between different types of nystagmus, such as end point nystagmus (EPN) and gaze evoked nystagmus (GEN)? If so, you're not alone. Working closely with therapists in vestibular therapy over the years we've found this to be a common issue. Given such, let's review three practical tips when assessing patients that we have found helpful.

Actually, before we get too far, we need to remember that end point nystagmus is a normal physiological response, while a true positive gaze evoked nystagmus finding is indicative of a central or peripheral vestibular disorder.

As we will see in this blog, end point nystagmus is a bit of a misnomer as it can be...

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...

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...

BPPV is the most common cause of dizziness across the lifespan. Fortunately with treatment it typically resolves within 1-3 sessions. Untreated, BPPV also has a 50% chance that it will resolve spontaneously within 3 months. (Bhattacharyya 2017)

So, what happens if the history of someone’s dizziness is consistent with BPPV, but it is not responding to treatment? It happens and we’ve been there. From our experience this could be due to several reasons, so let’s review the three most common reasons why.

Reason #1: You’re not using the correct technique to treat BPPV.

With any form of treatment, technique is vital. So, with BPPV let’s review some of the common...

As health care providers we like to say that we provide evidence based treatment, but what is the evidence for the vestibular therapy we provide? Specifically, how about the treatment we provide for vestibular hypofunction?

With being a busy clinician it can be a bit daunting trying to keep up with the latest research. We also have to realize that for every good piece of research there is research that is, well, not so good. So, how do we filter out the clinically relevant and strong evidence based research?

Fortunately, from time to time clinical practice guidelines come out and provide direction. Over the past few years there have been clinical practice guidelines developed for...