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Vestibular Therapy and Common Pitfalls to Avoid
By: Charmaine Shea, MScPT ∙ Estimated reading time: 3 minutes

Vestibular therapy woes?

Are your vestibular treatments unsuccessful? Are assessments leading you astray?

In this blog, we talk about common blind spots and bad habits so you can avoid them and significantly enhance patient outcomes! 

If you’ve ever felt lost in your vestibular practice, struggling to apply what you’ve learnt in a vestibular therapy course to clinical scenarios, or simply dabbling in this area, you’re not alone. Kregg Ochitwa provides some guidance on what you need to navigate the complexities of vestibular therapy with confidence.


Here's a sneak peek at Kregg's webinar: 


After reading this blog you will be able to: 

  • Differentiate if nystagmus is due to a vestibular condition or a false positive finding.
  • Identify why your treatment for BPPV, vestibular hypofunction or concussion might not be effective.

1. Getting false positives with gaze-evoked nystagmus testing

Ensure you are performing the test correctly by going through this checklist: 

  1. Take off your patient’s glasses - they might lose sight of your pen behind the rim of their glasses. This could lead to a false positive when they are searching for your pen. 
  2. Take their eyes laterally at 30 degrees - this decreases the chance of end-point nystagmus.
  3. Hold for at least 4 seconds - hold longer if they blink a lot.
  4. Determine gaze vs. end-point physiological nystagmus - as with end-point physiological nystagmus, it is of low amplitude, low velocity and is unsustained.


2. Not realising that Dix-Hallpike testing with BPPV can elicit any of the 3:

  1. Upbeat torsional nystagmus
  2. Lateral nystagmus
  3. Downbeat torsional nystagmus

Then, depending on the direction of the nystagmus we can treat the affected canal.

3. Not individualising vestibular exercises to match the individual's post-concussion stage or their sport

Should we be providing gaze stabilisation or habituation exercises for all patients with a concussion if it makes them dizzy?

We have to avoid cookie-cutter methods and focus on personalising each treatment intervention.

Here are some helpful tips: 

  • After ruling out BPPV and cervicogenic causes of dizziness, focus on gradually increasing daily activities for the first 7-10 days. 
  • If dizziness persists after this period, initiate vestibular exercises for desensitisation.
  • Symptoms can increase by 2/10 from their baseline, with a return to baseline within an hour. Latest research has indicated that we do not have to wait until patients are symptom-free to start exercising (Patricios et al., 2023).

4. Continued treatment for BPPV despite it not responding

Remember that BPPV resolves within 3 treatment sessions 97% of the time. If your treatment is not responding, ask yourself these questions:

  • Am I treating the wrong canal?
    • Remember that sometimes there could be a chance of multi-canal or bilateral involvement. There is also a 6-7% chance that with treatment the loose crystals went into a different canal. 

  • Am I not holding the position long enough?
    • Once the nystagmus is gone, make sure to wait an extra 30 seconds because it can take time for the crystals to move.

  • Am I treating something that is not BPPV?
    • There can be central pathologies that can mimic BPPV.



Adopting a systemic approach to assessment and treatment while acknowledging common blind spots can significantly improve patient outcomes and your confidence. Don’t be afraid to take a step back and reevaluate through a different lens, and remember to avoid cookie-cutter interventions! 

Now you know what common mistakes to avoid and we hope that you can navigate dizziness with confidence!

Want to learn more? Visit Kregg’s webinar for additional tips and tricks on common mistakes to avoid.

Take Kregg's Online Course:
Common Pitfalls In Vestibular Therapy

What this course offers

This course will teach you to differentiate between false positives and true vestibular conditions. You will also gain knowledge on why your current treatments for BPPV, vestibular hypofunction, and concussion may be unsuccessful, and discover strategies to enhance their effectiveness.

This course is intended for

Kregg’s online course welcomes physiotherapists and rehabilitation professionals who work closely with individuals struggling with migraines and/or dizziness. 

Additional courses

Whether you're a seasoned practitioner seeking to fine-tune your skills or just dipping your toes into the world of vestibular therapy, our vestibular courses are tailored to meet your needs.

Transform your practice and visit the vestibular course library from Embodia by clicking below.

Vestibular Courses
on Embodia




Patricios, J. S., Schneider, K. J., Dvorak, J., Ahmed, O. H., Blauwet, C., Cantu, R. C., ... & Meeuwisse, W. (2023). Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695-711.


Date published: 15 May 2024
Last update: 15 May 2024

Kregg Ochitwa

Kregg has been a registered physical therapist since 1995. Over the years his caseload has shifted from solely orthopedic to a mix of orthopedic and vestibular. With this background he has also established a reputation for treating concussion, having treated athletes in the NFL, CFL, college ranks, WHL, high school athletes, and the weekend warrior.

In 1998, he took his first course in the field of vestibular rehabilitation. In 2008, he completed all of the requirements of the Vestibular Rehabilitation: a competency based course at Emory University, Atlanta Georgia. Since then he has continued to take ongoing courses throughout North America in regards to orthopedics, traumatic brain injury, and vestibular therapy. He has also been asked to teach weekend courses and present at various conferences throughout North America and Europe.

In 2010, Kregg opened North 49 Physical Therapy in his hometown of Saskatoon, Saskatchewan. The clinic has since grown from a staff of one to seven physical therapists, where over half of the caseload consists of patients with dizziness and/or balance issues.

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