Positional Testing

15 February 2022
10 mins

What is positional testing?

Positional testing determines whether a change of position of the patient’s vestibular systems in space provokes nystagmus. Some nystagmus is only evident with changes in head position with respect to gravity. Both central and peripheral vestibular lesions can cause positional nystagmus and vertigo, and the examination focuses on distinguishing the two. Most central positional nystagmus is static, in that the nystagmus persists as long as the head is kept in the provoking position. Nystagmus produced as a result of Benign Paroxysmal Positional Vertigo, a peripheral vestibular pathology, is usually transient. Observations of the direction, latency and fatigability of nystagmus are important diagnostically.



  • Positional nystagmus is created by an asymmetry in the tonic resting rate of the two vestibular end organs
  • It is critical to identify the presence of spontaneous nystagmus prior to positional testing
  • There are many positions in which one might put the patient for examination The positions described in this paper are considered standard procedure and provide the most diagnostic information.
  • Positional testing is performed vision-denied (using covered VNG goggles) so that the patient does not have the means to suppress nystagmus
  • If the patient becomes strongly reactive when he is moved from one position to another, it is usually indicative of a vestibular lesion in the ear that is downward
  • If, within 15 seconds, no nystagmus is noted in the tracing, it is not necessary to continue the However, if nystagmus is noted, it is helpful to continue the recording for at least thirty (30) seconds to watch for decay.
  • Positional testing is also used in the diagnosis of benign paroxysmal positional vertigo (BPPV) of the lateral canal


Patient instructions

“I am going to place goggles over your eyes. I will then assist you in moving into different positions. It is important to keep your eyes open at all times so that the cameras can record your eye movement. I will also ask you some questions to help keep you alert during the test.”


Description of positions tested


1. Neutral

Used to rule out spontaneous nystagmus. The patient is in the seated position on the table with vision denied.


2. Supine

The patient is lying on the table, vision denied, while his head is supported by the examiner and elevated at approximately 30º (the approximate position of the head relative to the body in its natural state).


3. Head Right/Head Left and Body Right/Body Left

Begin with the patient in the supine position described above. Gently guide the patient’s head to one side. Allow adequate time for nystagmus to occur (approximately 15 seconds). If no nystagmus occurs, return the patient’s head to the center, and then turn the patient’s head in the opposite direction and repeat procedure. If nystagmus is noted in either the head right or head left positions, immediately ask the patient to roll onto his shoulder toward the side of the affected ear.


Normal positional testing results

If the patient does not have any form of positional nystagmus, the tracing will result in essentially a flat line for each position. The bar graphs for left and right beating nystagmus and down and up beating nystagmus will display as zero for all conditions.

Positional testing results overview, including supine, head left, and head right. The bar graphs for beating nystagmus are all zero, and they eye position tracings are almost flat in all positions.

Result showing a normal result for all positions tested.


Abnormal positional testing results

If positional nystagmus is present, nystagmus will be present in the horizontal and/or vertical channels. The nystagmus is represented by the triangles or green segments in the tracing and the averaged values for the strongest 10 seconds are shown in the bar graphs to the right of the tracing for each position.

Positional testing results overview, including supine, head left, and head right. For the supine subtest, the eye position tracings are slightly abnormal, resulting in left beating nystagmus with an average slow phase velocity of 3. For the head left subtest, the eye position tracings are rather jagged, resulting in left beating nystagmus with an average slow phase velocity of 11. For the head right subtest, the eye position tracings are also rather jagged, resulting in right beating nystagmus with an average slow phase velocity of 8. The head left and head right are flagged abnormal, with a red diamond for the whole subtest, and grey shaded regions in the bar graphs to indicate when the result has surpassed the threshold.

Result showing horizontal nystagmus, which is usually a peripheral finding.

Positional testing results overview for the head left subtest. Jagged eye tracing for the vertical position, resulting in down-beating nystagmus with an average slow phase velocity of 7.

Result showing vertical downbeat nystagmus, which is usually a central finding.


Connection between type of nystagmus and site of lesion

Nystagmus that persists as long as the provoking position is maintained can occur with either central or peripheral vestibular lesions. Review of the waveforms is helpful. Pure downbeat nystagmus from central lesions is often accentuated in the reclining position, and sometimes may only be noted with this position. The lack of a torsional component differentiates this from anterior canal BPPV. Pure upbeat nystagmus can be positional. Positional torsional nystagmus has been reported with lateral medullary infarction.

Other features that indicate central disease are lack of latency, lack of fatigability, and the inability to suppress nystagmus with vision. Patients with static positional nystagmus without prior evidence of more typical BPPV should be investigated for central disease. Lesions of the cerebellar vermis are especially associated with static positional nystagmus.


Alchohol effects on nystagmus

Alcohol can induce a static positional vertigo and horizontal nystagmus. Nystagmus beating towards the floor when the patient’s head is lying flat on its side emerges within 30 minutes of ingestion, peaking at 2 hours. As the blood alcohol level falls, 4 to 5 hours later, the nystagmus recurs in the opposite direction, and may last up to 12 hours. It is attributed to more rapid diffusion of alcohol into the cupula than the endolymph. The resulting difference in specific gravity temporarily imparts an abnormal sensitivity to linear acceleration, such as gravity.



For a complete discussion of positional testing and protocols, refer to:

Jacobson, GP, and Shepard, NT. Balance Functional Assessment and Management, 2nd Ed. San Diego; Plural Publishing, 2015

*NOTE: This is intended only as a guide, official diagnosis should be deferred to the patient’s physician.



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