Session 4: Positional and Gait testing

Question 1

What is the purpose of the Dix-Hallpike test? and what type of test is it?

Answer 1

-its a dynamic positioning test

• its one of the few tests that identifies a specific vestibular pathology
  -diagnoses posterior canal BPPV
• can also provide evidence for peripheral vestibular lesions as well as central lesions

Question 2

should Dix- Hallpike be used as a standalone test?

Answer 2

no, as part of a larger vestibular test battery to provide a comprehensive view of the patients balance system and history

Question 3

How is the Dix Hallpike test observed?

Answer 3

• via direct observation by the tester in front of the patient
• using Frenzel or magnifying lenses- easier to see nystagmus
• recording with VNG goggles (these goggles are only for recording eye movements, not for analysing torsional elements)

Question 4

What are the steps of the DIx Hallpike test procedure?

Answer 4

1- Explain procedure & obtain informed consent.
2- Ensure understanding that dizziness or vertigo may occur.
3- Position the patient on an examination couch, seated with their legs extended.
4- Turn the patient’s head 45 degrees towards the ear being tested (test ear).
5- With the patient’s head supported, guide them quickly into a lying position with their head hanging 20–30 degrees below the horizontal edge of the couch.
6- Maintain the 45-degree head turn.
7- Observe the patient’s eyes for nystagmus (abnormal eye movements) and ask about any vertigo symptoms.
8- Note the latency, direction, and duration of nystagmus and vertigo (if present).
9- Hold this position for at least 30seconds-2 mins or until nystagmus subsides.
10- Assist the patient back to a seated position while maintaining their head rotation.
11- Observe for reversal of nystagmus, which may occur when sitting up.
12- Repeat on Opposite Side:
13- If the test is negative on the initial side, repeat the procedure for the opposite ear.

• *Interpretation:
• Positive for BPPV: Torsional, up-beating nystagmus with latency and vertigo indicates posterior canal BPPV.
• Negative: No nystagmus or symptoms. Consider other tests if history strongly suggests BPPV.

Question 5

what are some important things you need to remember for the Dix Hallpike test procedure?

Answer 5

▪ The patient’s head must be supported in the supine position to avoid discomfort
▪ The patient should be encouraged to keep their eyes open so that they any eye
movement can be recorded/observed
▪ Reassurance is needed during this test as it involves putting the patient in an
unusual position and it can also induce dizziness
▪ Staying in each position during the Dix-Hallpike position should be emphasised,
especially if any dizziness occurs
Important notes- the test can induce tinnitus

Question 6

what are normal test results for the Dix - Hallpike test?

Answer 6

Normal: No dizziness or nystagmus

Question 7

what are test results for the Dix - Hallpike test for a patient with BPPV? 1- what would you see in the effected side?what onset?how long does it last?

Answer 7

BPPV:
▪ testing the affected side causes an immediate or delayed onset
▪ torsional nystagmus lasting up to a minute
▪ Fatigues when the manoeuvre is repeated

Question 8

what happens if you repeat a Dix- Hallpike test?

Answer 8

• fatigue when test is repeated

Question 9

what is some other information that a Dix Hallpike test can give?

Answer 9

▪ Other peripheral vestibular lesions: horizontal positional nystagmus
▪ Central lesions: horizontal, vertical or direction-changing nystagmus
Test Results

Question 10

for the Dix-Hallipke test, why is it important to observe the direction of the nystagmus?

Answer 10

• The direction of the nystagmus can identify which SSC is
  affected:
  ▪ Posterior canal: up-beating torsional nystagmus
  towards the affected ear
  ▪ Anterior canal: down-beating torsional nystagmus
  towards the affected ear
  ▪ Horizontal canal: horizontal nystagmus beating either
  towards or away from the ground
  BPPV Results

Question 11

what does the onset of the nystagmus tell us about the BPPV for Dix Hallpike

Answer 11

• Delayed Onset (2–20 seconds):
  +Indicates canalithiasis (free-floating otoconia in the canal).
  +Nystagmus lasts less than 1 minute and may reverse when the patient sits up.
  Immediate Onset:
• Indicates cupulolithiasis (otoconia stuck to the cupula).
  +Nystagmus lasts longer than 1 minute.
• Why Delayed Onset Happens:
  +In canalithiasis, fluid movement caused by otoconia lags, leading to a delayed stimulation of the cupula.

*observe direction and latency of nystagmus

Question 12

what should you do if theres no nystagmus after Dix- Hallpike test?

Answer 12

If there is no nystagmus this does not always meant there is
no BPPV
▪ The response could fatigue
▪ There could be other balance problems

Question 13

what should you do if the patient cant do Dix- Hallpike due to neck or back problems?

Answer 13

• Alternative positional test:
  ▪ Side-lying test:
  ▪ Performed when the Dix-Hallpike might induce neck or back pain.
  ▪ Diagnoses BPPV and provides evidence to support other
  peripheral or central pathologies depending on the nystagmus
  induced

▪ Roll test: Performed to diagnose horizontal canal BPPV

Question 14

what are posture and gait tests used for?

Answer 14

Posture and gait test can be used to supplement
other tests to help identify vestibular and other
pathologies.

Question 15

what are the 4 gait tests?

Answer 15

1 -Romberg/ Sharped Romberg
2 -CTSIB (clinical test of sensory integration imbalance)
3 -Unterberg test (aka the Fukuda Stepping test)
4- posture test

Question 16

what info does the Romberg/Sharpened Romberg test provide, what is it based on?

Answer 16

• Provides an objective measurement of postural stability.
• Based on the idea that removing information from a sensory input causes changes in posture

Question 17

what are some advantages and disadvantageous of the Romberg/ Sharpened Romberg test?

Answer 17

Advantage:
- Simple non intrusive test
- Cheap (no equipment required)
- May give subjective information about difficulties maintaining posture.
Disadvantage
- Results are subject to variations interpretation
- Limited evidence for diagnosing a vestibular pathology
- Learning effects/r can affect the subject’s ability to perform the test

Question 18

how do you complete the Romberg test?

Answer 18

-stand on solid ground
- feet apart
-hands by their side
-complete test eyes open
-complete test eyes closed- VS problem- the patient will start swaying side to side?

Question 19

what is the CTSIB (clinical test of sensory integration imbalance) test?

Answer 19

• gloried romberg test
• you complete the test in the same was as romberg but ask the patient to stand on a cushion or foam with feet apart, eyes open and ten eyes closed

-its a pass or fail test and the patient fails if they make a corrective movement with their feet in order to stay upright

• Gives information about which sensory input the patient relies on for good balance.
• Some evidence to show that the test is good for distinguishing between patients with and without
  vestibular disorders

Question 20

what is the Unterberg test (aka the Fukuda Stepping test) used for?

Answer 20

• you ask the patient to march on the spot for a set amount of time with their eyes closed

Originally intend as test of vestibular function. The test reflects somatosensory function more than
vestibular function.
- Patient marches on the spot for a set length of time with their eyes closed.
- A specific amount of rotation (varies from 30-60 degrees) is taken to suggest the presence of a
vestibular lesion on that side.
- Poor relationship between side of peripheral vestibular lesion and direction of patient turn

Question 21

what does the gait test involve and what info does it provide?

Answer 21

• Tests which involve walking (under normal circumstances and under test conditions)
• Provides limited information about the patients vestibular function
• Provides significant information regarding the patient’s disability.

Question 22

what are the 4 types of gait testing?

Answer 22

• Normal gait: ask patent to walk normally in a straight line
• Tandem gait: ask patient to walk heel to toe
• Ambulation with head rotation: asking the patient to walk in a straight line moving their head from left to right
• Ambulation with stop and turn: ask patient to walk in a straight line, make a sudden stop and walk back in the direction the patient came from.

Question 23

what are some disadvantages of the Gait test?

Answer 23

Disadvantages:
- Many different forms gait testing - Quite subjective - Affected by other factors
Gait testing

Question 24

should gait testing be used as a standalone diagnostic test?

Answer 24

the VOR, Gait and posture test can NOT be used as a diagnostic feature but can be used to assist with diagnoses. This battery of tests helps clinician identify whether there’s a peripheral or central problem

Question 25

what are the 3 posture tests?

Answer 25

1 -Romberg/ Sharped Romberg
2 -CTSIB (clinical test of sensory integration imbalance)
3 -Unterberg test (aka the Fukuda Stepping test)

Question 26

name 3 VOR tests?

Answer 26

1- Head impulse test
2- Headshake
3- Dynamic Visual Acuity

Question 27

Why are back or neck problems important to consider before positional tests?

Answer 27

Back or neck issues like cervical spine fractures, atlanto-axial subluxation, or odontoid peg fractures are absolute contraindications. Alternative methods like the side-lying test should be used to avoid harm.

Question 28

How should mobility issues be managed during vestibular tests?

Answer 28

Patients with limited mobility may need modifications such as using pillows for support, performing tests on a wide couch, or employing the side-lying method. Assistants or chaperones can also help ensure safety and comfort.

Question 29

How can anxiety impact vestibular testing, and what should clinicians do?

Answer 29

Anxiety may cause tension or noncompliance, affecting test outcomes. Clinicians should reassure patients, explain the procedure clearly, and obtain informed consent to reduce anxiety.

Question 30

What role do eye issues, like nystagmus or recent eye surgery, play in testing?

Answer 30

Pre-existing eye conditions or recent surgeries (within 3 weeks) can interfere with observing test-induced nystagmus. Baseline eye movements must be accounted for to avoid misdiagnosis.

Question 31

How can medications affect vestibular test results?

Answer 31

Vestibular-suppressant medications can reduce test sensitivity by suppressing nystagmus. Tests should be scheduled when the medication’s effects have worn off.

Question 32

Why should recent alcohol intake be avoided before testing?

Answer 32

Alcohol can alter vestibular function and nystagmus patterns, leading to skewed results. Patients should abstain from alcohol before testing.

Question 33

What are the general contraindications for positional tests according to the BSA?

Answer 33

Absolute contraindications include recent or unstable cervical spine fractures, atlanto-axial subluxation, fractured odontoid peg, and recent eye surgery.

Question 34

What modifications does the BSA recommend for positional tests for patients with contraindications or challenges?

Answer 34

Recommended modifications include the side-lying test, use of pillows for support, slower testing movements, or the assistance of additional staff to ensure safety.

Question 35

why is static positional testing used?

Answer 35

• identifies nystagmus caused by specific head and body positions.
• the patient is moved slowly into the relevant position and their eye movement are monitored (using ENG/ VNG) with and without fixation.
• If the ENG/ VNG trace shows nystagmus this may indicate a peripheral or central pathology is present

Question 36

what are the positions for static positional testing?

Answer 36

-preciously up to 10 diff body and head positions were used to assess patients but now BSA recommends the following positions:
- supine
- body right
- body left
- supine with neck flexion at 30 degrees
- Any positions described by the patient as inducing nystagmus

Question 37

what are the steps involved in the process of testing static positional testing?

Answer 37

1- patient moves slowly into position
2- eye movements are recorded for 30 seconds without fixation if no nystagmus occurs, and for up to several minutes if nystagmus is present.
3- If nystagmus is recorded without fixation, continue recording with fixation to determine if suppression occurs.
4- the test may be conducted with or without mental alerting techniques

Question 38

When are results considered abnormal in static positional testing?

Answer 38

• nystagmus changes direction in a single position;
  and/or
• nystagmus of 6º/s or greater in any one position
  and/or
• nystagmus greater than 3º/s in three (or more) out of four positions

Question 39

What factors determine whether nystagmus is interpreted as a peripheral or central finding during testing?

Answer 39

Nystagmus is generally considered a peripheral finding unless it exhibits specific central characteristics or is supported by central features in other test results.