Vestibular First

🥇The modified Epley Maneuver is THE gold-standard treatment for posterior canalithiasis BPPV, the most common form of episodic positional vertigo.

💎Why use the term “modified?” This familiar version is actually an update to Dr. John Epley’s original version from the 1980’s. His version used vibration over the mastoid on the affected side and restrictions in postures/positions after the treatment, both of which have since been proven unnecessary (they do not improve outcomes).

📊 EFFECTIVENESS: Resolves posterior canal BPPV in ~80–90% of patients within 1–3 treatments. It carries a “Level A” recommendation in the Clinical Practice Guideline for BPPV (Bhattacharyya et al., 2017). BPPV recurrence is ~10–30% within a year, especially with risk factors like older age, history of head trauma, osteoporosis, migraine history, high blood pressure, diabetes, and/or low vitamin D levels.

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

✅Starting Position: Patient in long sitting (legs out).

1. Turn head 45° toward the affected (left) side.

2. Lie back quickly, extending the neck 20–30° over the edge of the table or over a pillow. Hold until nystagmus stops plus ~20 sec.

3. Rotate head 90° toward the unaffected (right) side. Hold until nystagmus stops plus ~20 sec.

4. Roll body and head a further 90° into right side-lying, face angled downward toward the table. Hold until nystagmus stops plus ~20 sec.

5. Return to sitting on the edge of the table, keeping your head turned and chin tucked toward your chest (CHIN TUCKED DOWN IS ESSENTIAL). Maintain this position for ~1 minute, then slowly center the head at the midline and neutral position.

6. Repeat if needed.

🎁 v1st.co/epleyhandout for a FREE printable pdf of the (modified) Epley maneuver!

⚠️ Always consult a qualified vestibular specialist before attempting any BPPV maneuvers. Educational purposes only.

👑Post created in collaboration with Sonia Vovan, PT, PhD(c) ().

🧠👁️ Dizzy with neck motion? This cervical joint position sense training activity has the potential to improve the integration of sensory input from the neck, vestibular system, eyes, and brain. It may also help decrease sensitivity to self-motion.

🏮👷 Start with a headlamp laser (an affordable option is the Mustools 2026 New Rechargeable LED Laser Headlamp Physical Therapy on Amazon, or choose the more durable, multi-purpose version by Motion Guidance). Place a Post-it note with a single letter on the wall.

🎯🔼🔽 Turn your head in different directions, first with eyes open, following the instruction: “Keep your eyes focused on the laser.”

😆❤️ Close your eyes, turn your head, and try to return your head to the starting center position with the laser directly on the target. Repeat with different directions of head movement, different speeds of head movement, and with different ranges of motion.

🪅🎈Want a free printable joint position error target? Get yours at v1st.co/jpe today!

🛻🥫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 with alphabet letters on it (which can be purchased online) and Hart charts.

🔠🅰️ 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).

🎉🎈We have free printable pdf HART charts for you at v1st.co/freeHART!

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

🪭🪩Try swinging the ball forward and back, then side to side for a different challenge. Then add a busy visual background like a video behind the Hart chart.

🎬🚦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 focus is to train the brain to prioritize certain sensory information instead of getting overwhelmed.

🏆🧰 Get free printable pdf Hart charts to use for vestibular rehabilitation at v1st.co/freeHART