Session 4: Positional and Gait testing Flashcards
What is the purpose of the Dix-Hallpike test? and what type of test is it?
-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
should Dix- Hallpike be used as a standalone test?
no, as part of a larger vestibular test battery to provide a comprehensive view of the patients balance system and history
How is the Dix Hallpike test observed?
- 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)
What are the steps of the DIx Hallpike test procedure?
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.
what are some important things you need to remember for the Dix Hallpike test procedure?
▪ 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
what are normal test results for the Dix - Hallpike test?
Normal: No dizziness or nystagmus
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?
BPPV:
▪ testing the affected side causes an immediate or delayed onset
▪ torsional nystagmus lasting up to a minute
▪ Fatigues when the manoeuvre is repeated
what happens if you repeat a Dix- Hallpike test?
- fatigue when test is repeated
what is some other information that a Dix Hallpike test can give?
▪ Other peripheral vestibular lesions: horizontal positional nystagmus
▪ Central lesions: horizontal, vertical or direction-changing nystagmus
Test Results
for the Dix-Hallipke test, why is it important to observe the direction of the nystagmus?
- 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
what does the onset of the nystagmus tell us about the BPPV for Dix Hallpike
- 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
what should you do if theres no nystagmus after Dix- Hallpike test?
If there is no nystagmus this does not always meant there is
no BPPV
▪ The response could fatigue
▪ There could be other balance problems
what should you do if the patient cant do Dix- Hallpike due to neck or back problems?
- 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
what are posture and gait tests used for?
Posture and gait test can be used to supplement
other tests to help identify vestibular and other
pathologies.
what are the 4 gait tests?
1 -Romberg/ Sharped Romberg
2 -CTSIB (clinical test of sensory integration imbalance)
3 -Unterberg test (aka the Fukuda Stepping test)
4- posture test
what info does the Romberg/Sharpened Romberg test provide, what is it based on?
- Provides an objective measurement of postural stability.
- Based on the idea that removing information from a sensory input causes changes in posture
what are some advantages and disadvantageous of the Romberg/ Sharpened Romberg test?
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
how do you complete the Romberg test?
-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?
what is the CTSIB (clinical test of sensory integration imbalance) test?
- 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
what is the Unterberg test (aka the Fukuda Stepping test) used for?
- 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
what does the gait test involve and what info does it provide?
- 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.
what are the 4 types of gait testing?
- 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.
what are some disadvantages of the Gait test?
Disadvantages:
- Many different forms gait testing - Quite subjective - Affected by other factors
Gait testing
should gait testing be used as a standalone diagnostic test?
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
what are the 3 posture tests?
1 -Romberg/ Sharped Romberg
2 -CTSIB (clinical test of sensory integration imbalance)
3 -Unterberg test (aka the Fukuda Stepping test)
name 3 VOR tests?
1- Head impulse test
2- Headshake
3- Dynamic Visual Acuity
Why are back or neck problems important to consider before positional tests?
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.
How should mobility issues be managed during vestibular tests?
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.
How can anxiety impact vestibular testing, and what should clinicians do?
Anxiety may cause tension or noncompliance, affecting test outcomes. Clinicians should reassure patients, explain the procedure clearly, and obtain informed consent to reduce anxiety.
What role do eye issues, like nystagmus or recent eye surgery, play in testing?
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.
How can medications affect vestibular test results?
Vestibular-suppressant medications can reduce test sensitivity by suppressing nystagmus. Tests should be scheduled when the medication’s effects have worn off.
Why should recent alcohol intake be avoided before testing?
Alcohol can alter vestibular function and nystagmus patterns, leading to skewed results. Patients should abstain from alcohol before testing.
What are the general contraindications for positional tests according to the BSA?
Absolute contraindications include recent or unstable cervical spine fractures, atlanto-axial subluxation, fractured odontoid peg, and recent eye surgery.
What modifications does the BSA recommend for positional tests for patients with contraindications or challenges?
Recommended modifications include the side-lying test, use of pillows for support, slower testing movements, or the assistance of additional staff to ensure safety.
why is static positional testing used?
- 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
what are the positions for static positional testing?
-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
what are the steps involved in the process of testing static positional testing?
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
When are results considered abnormal in static positional testing?
- 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
What factors determine whether nystagmus is interpreted as a peripheral or central finding during testing?
Nystagmus is generally considered a peripheral finding unless it exhibits specific central characteristics or is supported by central features in other test results.
