A 76-year-old man presented with a 2-week history of intermittent episodic rotational vertigo accompanied by blurred vision, vomiting, and imbalance. Neurologic examination revealed no sensory, motor, or cranial nerve deficits. However, the head impulse, nystagmus, and test of skew (HINTS) exam demonstrated right-beating nystagmus that intensified with visual suppression, a vertical skew deviation with right hyperphoria, and a normal vestibulo-ocular reflex (VOR) on video head impulse testing (vHIT), except for clustered refixation saccades for rotations in the plane of the left horizontal semicircular canal. Following a thorough workup, a posterior fossa stroke was ruled out and the patient was diagnosed with vestibular migraine (VM) and Meniere's Disease (MD). This case highlights the diagnostic considerations for episodic vestibular syndrome (EVS) in a patient with significant cardiovascular risk factors. We discuss the differential diagnosis, emphasizing the need for thorough history, targeted examination, and imaging to refine diagnostic interpretation, particularly in the context of positive skew deviation.

ObjectivesPeripheral vestibular hypofunction (PVH) affects a significant portion of the population and impairs visual acuity during head motion (dynamic visual acuity, DVA). This study compared the effectiveness of a novel gaze stability training called Incremental VOR Adaptation (IVA) versus traditional vestibular physical therapy (VPT) for improving DVA.MethodsThe Incremental Velocity Error as a New Treatment in Vestibular Rehabilitation (INVENT) trial is a randomized, controlled, cross-over study involving 24 participants with chronic unilateral or bilateral PVH. Participants underwent either IVA or VPT for 3 weeks, followed by a washout period and then the alternate intervention (IVA-VPT or VPT-IVA). DVA was measured at baseline, after each intervention, at the completion of the washout period, and at 6-month follow-up.ResultsThere was a significant main effect of treatment Group, F (1,19) = 7.75, p = 0.012, with (IVA-VPT) consistently demonstrating lower DVA scores than VPT-IVA. A significant main effect of Side was also observed, F (1,19) = 13.35, p = 0.0017, indicating lower DVA scores for contralesional compared to ipsilesional head rotation. We found no effect of Time (F (4,76) = 1.44, p = 0.23), suggesting that scores remained stable from baseline through the 6-months follow-up. There were no significant interactions, including Group × Side (F (1,19) = 0.11, p = 0.74), Group × Time (F (4,76) = 1.33, p = 0.27), or Group × Side × Time (F (4,76) = 0.59, p = 0.67).ConclusionDVA scores were consistently better at all time points after participants completed IVA. Using an intent to treat analysis, with no baseline demographic differences between groups, our data support that exposure to the first gaze stability training type exerts a stable influence on DVA that persisted to 6-month follow-up. Clinically, this implies that once DVA improvements are established through either IVA or VPT, they tend to remain stable over 6 months.Level of EvidenceLevel 2.

The clinical diagnosis of benign paroxysmal positional vertigo (BPPV) is confirmed from observing the direction, intensity, and duration of nystagmus from unique head positions that advantage gravity to overcome the inertia of otoconia displaced inside the semicircular canals. This case series highlights BPPV with atypical nystagmus presentations relative to the head position. Clinicians should carefully observe symptoms and nystagmus presentations regardless of the testing position and utilize technology and rules of vestibular physiology to enhance their diagnostic acumen.

This clinical perspectives article provides a comprehensive and evidence-based overview of diagnosing and treating dizziness in complex patients. These patients typically present with overlapping comorbidities and symptoms that can create difficulty in discovering an accurate diagnosis and treatment plan. Vestibular dysfunction affects over 35% of adults older than 40 years, and that prevalence significantly increases with age. Eighty-five percent of adults older than 80 years had evidence of balance/vestibular dysfunction. We believe this differential diagnosis between cardiopulmonary and vestibular dizziness transcends all rehab environments across the continuum of care. We will provide evidence for vestibular background knowledge and clinical skills that intersects with evidence regarding pharmacology and competing cardiopulmonary diagnoses to provide clinicians with the framework, skills, and knowledge to differentially diagnose dizziness across multiple care settings. In addition, we will provide examples of appropriate interdisciplinary communication to assist the clinician in decision making and best practice management.

Purpose of review Benign paroxysmal positional vertigo (BPPV) can be diagnosed and treated at bedside with positional testing and maneuvers. Appropriate and timely recognition and treatment for BPPV can ameliorate symptoms of vertigo and spinning, reduce fall risk and healthcare costs, and minimize disability. Although medications may transiently reduce symptoms, they do not address the underlying pathology. Treatment typically includes the Epley or Semont maneuvers for posterior canal BPPV, the Gufoni or BBQ (Lempert) maneuvers for horizontal canal and the Yacovino or deep head hang maneuver for the anterior canal BPPV. Recent findings BPPV can be successfully treated with multiple maneuvers. As multiple maneuvers are efficacious, clinicians can select the maneuvers based on their preference, complexity of the maneuvers themselves, patient response to other maneuvers, and factors of the patient’s profile including body habitus and musculoskeletal considerations. Summary The purpose of this manuscript is to simplify the diagnosis and treatment of BPPV and make these techniques accessible to all healthcare providers.

This case demonstrates the successful identification and treatment of atypical posterior semicircular canal benign paroxysmal positional vertigo (BPPV) based on a unique presentation of positional nystagmus, the resultant nystagmus from repositioning manoeuvers, and restored function of the affected semicircular canal. This case illustrates the importance of completing a comprehensive clinical examination and the value for incorporating the video head impulse test as well as adjusting treatment based on testing and patient response when managing variant cases of BPPV.

Background Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period. Objective To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT). Methods A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day. Results There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC. Conclusions Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.