Vestibular First

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Vestibular First

Our mission is to create simple, effective, affordable, and ubiquitous vestibular technologies.

Our mission is to create simple, effective, affordable, and empowering vestibular technologies to help improve the lives of those suffering from vestibular disorders.

08/25/2026

🚩🚩🚩 New nystagmus that suppresses in the DARK and is visible in the LIGHT? Major red flag for possible/likely central (brain) pathology!

📚❤️‍🩹 A 36-year-old male presented with sudden-onset vertical diplopia (double vision), dizziness, and slurred speech. He had a history of arrhythmogenic right ventricular dysplasia (rare genetic heart condition).

🕵️🧩 Findings on exam:
Infrared video goggles showed hemi-seesaw nystagmus (HSSN) with visual fixation (LIGHT), consisting of intorsional upbeat nystagmus in the right eye occurring synchronously with extorsional downbeat nystagmus in the left eye (counterclockwise from the patient’s perspective). This nystagmus suppressed in the DARK.
Bilateral upward gaze palsy with partial impairment of downward gaze (oculomotor sign).
Vertical saccades and smooth pursuit were impaired due to the vertical gaze palsy.
The horizontal canals were normal per video head impulse test, making peripheral vestibulopathy unlikely.
🧠🚩 MRI brain revealed acute infarction in the left medial thalamus and upper midbrain.

🏆✅ This case example is from an excellent paper by Kim et al. (2023) entitled “Visual Fixation-Induced Hemi-Seesaw Nystagmus,” so I’d like to give full credit to those researchers for this helpful video learning opportunity.

🤔⛔ Important lesson: Don’t assume a 36-year-old can’t have a stroke! If new central signs are present, it’s time for MRI brain imaging and other relevant tests (MRA, etc.) as appropriate.

🔥Want to learn more? v1st.co/CEUforyou to explore our online and in-person continuing education courses.

🛟 Want to help more patients? Join dz.care/join to be a part of a fantastic network of clinicians in the U.S. striving to help patients with dizziness every day!

08/24/2026

What can we expect to see on common oculomotor tests? Meet us in Philadelphia this October 3, 2026 for a stellar hands-on training for our hybrid intro vestibular certification, and watch v1st.co/CEUforyou for an amazing 2027 intro and intermediate course schedule!

08/20/2026

⚡ The Quick Liberatory Rotation (QLR) maneuver treats posterior canalithiasis BPPV, using quick movement like a Semont (Califano et al., 2003).

🚀 Some clinicians even choose the QLR to treat posterior cupulolithiasis, although no official research exists on its efficacy for this type of BPPV.

✅ Pros: Great for patients with excellent mobility but increased nausea during sitting up/lying down movements.

⛔ Not for patients with limited cervical mobility, neck trauma, or cervical disc herniation. Requires the patient to be able and tolerant of a rapid body roll from side lying on one side to side lying on the other. Total time: ~8 minutes

📊 EFFECTIVENESS: In the original single-centre randomized trial, it cleared 80% of patients in 1 rep and roughly 98% within three, comparable to the Semont and Epley.

🏆Bonus: a secondary liberatory nystagmus (upbeat and torsional toward the affected side) was present in about 76% of treatments when the nose was down (position 2). This is generally considered a good sign that the particles are clearing.

📝 STEP-BY-STEP PROTOCOL (LEFT EAR example): A clinician assesses, guides, and assists throughout.

▶️ Starting Position: Bring the patient into the left Dix-Hallpike position, head turned about 45° toward the affected (left) ear and in 20-30 degrees of neck extension.

1. Hold the first position (left Dix-Hallpike) for ~2 minutes after the nystagmus and symptoms subside.
2. Within one second, have the patient rapidly roll into right side lying (onto the unaffected side) with the nose down. For position 2, the head should be turned 45° toward the unaffected side while the nose points toward the ground (mirroring position 3 of the modified Epley).
3. Maintain the final nose-down position for 2 minutes after any nystagmus subsides, or 4 minutes if none appears.
4. Return to sitting with the chin tucked down, monitoring for nystagmus and symptoms. Repeat up to 3 times if needed.
⚠️ Always consult a qualified vestibular specialist for BPPV maneuvers. Educational purposes only.

dz.care/vestibularfirst to find a provider.

🖊️ collaboration with Sonia Vovan, PT, PhD(c) (Sonia Vovan | Concussion + Vestibular Physiotherapist).

08/19/2026

Ready to learn more? v1st.co/Sara26 for an AMAZING 1.5 hour vestibular webinar on complex vestibular diagnosis and treatment TONIGHT (Wednesday, August 19 at 7:15 PM Eastern), live only (not recorded), for a DEAL at $10 (US dollars). See you there! Live Your Life Physical Therapy, LLC

08/17/2026

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08/13/2026

🟥👋 Have you seen this eye movement, and is it normal? It can be normal, don’t worry!

👁️🦘 This video shows a person with “square wave jerks,” which are pairs of left/right saccades (eye “jumps”) that move the eyes away and then return them to fixation. They are often repeated, followed by a “rest” before the next set of jerks.

🤨💃 At first, it seems like someone is looking around voluntarily, until a PATTERN of repeated “bursts” of square wave jerks emerges with ongoing observation.

📈 📚 These involuntary eye movements are called “square wave” because of how they appear on an eye tracking software graph.

🎯🧠 Square wave jerks (SWJs) appear in some patients with Parkinson’s, progressive supranuclear palsy (PSP), ALS, Alzheimer’s disease, Multiple System Atrophy, cerebellar dysfunction (ataxias, Chiari, etc.), schizophrenia, OCD, bipolar disorder, autism, and anorexia nervosa.

🛜☎️ In general, SWJs sometimes indicate neural circuit issues in certain parts of the brain, including cortico-cerebellar pathways.

🫆🧩 Interestingly, those with PSP exhibit a significantly higher SWJ rate, a higher SWJ rate to blink rate ratio, and a lower blink rate than those with Parkinson’s. This offers a possible avenue for differential diagnosis when using VNG with eye tracking software.

🚦⚠️ However, square wave jerks ALSO reportedly occur in 24-60% of HEALTHY adults and 90% of HEALTHY children ages 8-19.

🔑✅ The key differentiating factor is NOT the presence of square wave jerks alone, but rather whether there are other abnormal oculomotor and/or neurologic screening findings, as well as considering the patient history (example: known schizophrenia).

💯 If I see square wave jerks as a vestibular physiotherapist, you know I’ll conduct a THOROUGH history and examination, including using the Dizzy Care Network for their amazing free patient history questionnaire.

🏆🟢Join the Dizzy Care Network as a clinician at dz.care/FreeDCN or if you’re a patient seeking care, use dz.care/vestibularfirst

(Nowinski et al., 2005; Altiparmak et al., 2006; Salman et al., 2008; Phillipou et al., 2019; Zachou et al., 2024)

08/12/2026

Are you optimizing BPPV, balance, and VORx1 training and care? Save these charts and visit v1st.co/trainwithus to register for some AWESOME upcoming in-person vestibular courses!

08/11/2026

🛻🥫Dizzy when viewing moving traffic or walking down a grocery store aisle? 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.

⚾Ⓜ️ This activity uses a string-suspended Marsden ball or a baseball marked with numbers (which you can purchase online or make yourself with a marker and a ball). You will also need number circles (purchase velcro ones online or make your own with paper and marker).

🆚🆔In this activity, the goal is to progress to alternating between finding a letter on the Marsden ball and finding a number on the floor.

🪭🪩Try swinging the ball forward and back, then side to side for a different challenge. Then add a catching a numbered die to establish the number (the first one you see) that you must then find on the swinging ball and the number on the floor.

🎬🚦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 number “3” while pressing your feet firmly into the ground.”

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

📚 Learn more! Check out our intro and intermediate in-person vestibular courses for 2026: v1st.co/trainwithus

🏆Access dz.care/vestibularfirst to connect vestibular specialist clinicians with persons with dizziness and imbalance.

08/06/2026

🏔️ 🧰 Need more options to progress walking over uneven surfaces like grass or curbs for balance training? These ideas use a foam beam, but if you don’t have one, you can also line up a few foam pads or couch cushions.

🍄💧Add river stones and balance pods, and we’ve got a real somatosensory or proprioceptive loaded challenge!

⚠️ 🚧 Be sure to look forward occasionally since prolonged downward gaze sometimes makes people dizzy. Balance activity should be guided, recommended, and guarded for safety by a trained clinician.

🧠 v1st.co/CEUforyou (Page 2) to register for our in-person intermediate courses on vestibular rehab for PPPD, vestibular migraine, and Atypical BPPV. Join us in San Francisco or Orlando this fall 2026!

08/04/2026

🧰Need a new tool in the toolbox for horizontal canal BPPV? The Modified Zuma Maneuver is designed to treat the geotropic variant of horizontal (lateral) canal BPPV (canalithiasis).

🐢 When to use it? If you have a very nauseous patient, this maneuver is slow and gentle. It takes about 10 minutes, so don’t choose it if you’re in a hurry.

↔️ Why is this maneuver called “modified Zuma”? The original Zuma was built for the apogeotropic variant of horizontal canal BPPV (cupulolithiasis). This modified version adds one change: a 45 degree head turn toward the unaffected side in the seated starting position, to adapt it for horizontal canalithiasis.

📊 EFFECTIVENESS: The modified Zuma was described in a SMALL case series where it cleared geotropic lateral canal BPPV in EVERY case after a single application, reassessed one hour later (Ramos et al., 2020). We need more research on this maneuver!

🏆A virtual-simulation study has since suggested the Zuma maneuvers are better at ensuring that inner ear crystals do not move into a different canal during treatment, compared to traditional horizontal canal treatment options, but we need real world patient studies to confirm or disprove this claim.

📝 STEP-BY-STEP PROTOCOL (LEFT EAR, geotropic): A clinician assesses, guides, and assists throughout.

▶️ Starting Position: Patient seated, with geotropic lateral canal BPPV confirmed on the supine roll test.

1. Turn the head 45 degrees toward the unaffected (right) side.
2. Keeping that head turn, lie down onto the affected (left) side. Hold about 3 minutes.
3. Roll into dorsal decubitus, face up, with the head turned 45 degrees toward the unaffected (right) side. 4. Hold about 3 minutes.
5. Continue turning the head to 90 degrees toward the unaffected (right) side, a further 45°. Hold about 3 minutes.
6. Tilt the head slightly forward, then return slowly to sitting.
⚠️ Always consult a qualified vestibular specialist before attempting any BPPV maneuvers. Educational purposes only.

🖊️ Post created in collaboration with Sonia Vovan, PT, PhD(c) (Sonia Vovan | Concussion + Vestibular Physiotherapist).

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