Balance
Updated March 2021 by Michelle Petrak, Ph.D.
Tips before performing the roll test
Please consider the following before you begin the test.
1. Past injuries
Before performing the roll test, it is important to find out whether the patient has current or past injuries of the neck or spine.
2. Neurological symptoms
If neurological symptoms occur during the roll test, stop the test immediately and refer for a neurological evaluation.
These symptoms might include, blurred vision, numbness, weakness of the arms or legs or confusion.
3. Allow enough time for otoconia displacement
It is important to remember that the consistency of fluid inside the vestibular system is viscous.
Thus, you should allow enough time within each of the positions for the otoconia to achieve most displacement.
This condition may also be responsible for a delayed onset of nystagmus.
4. Video Frenzel or VNG goggles
It is most helpful to use Video Frenzel or VNG goggles when performing the roll test.
This reduces the ability of the patient to fixate during the procedure to reduce the nystagmus response.
This will also allow the examiner to see even very slight horizontal nystagmus.
5. Test both ears
It is common for the patient to tell you during the intake interview which ear is affected and will describe accurately the symptoms of BPPV.
Use this information to determine which ear is likely the affected ear.
Always test both ears, even if the patient complains of only one side being affected.
6. Sensitivity towards horizontal canal BPPV
Patients are often very sensitive to horizontal canal BPPV, resulting in severe dizziness and vomiting.
If the patient reacts violently during the roll test, immediately turn the patient to the opposite side and perform a Lempert 360-degree roll.
How to perform the roll test
I have outlined the steps below.
Step 1
Begin with the patient sitting length-wise on the examination table.
Place the Frenzel/VNG goggles on the patient.
Step 2
Guide the patient into a supine position.
A slight elevation of the head (approximately 20 degrees) is helpful.
Step 3
Turn the patient’s head 90 degrees to either side (Figure 1).
If the patient does not have enough cervical flexibility to provide most otoconia displacement, have the patient roll onto his/her shoulder.
Observe whether nystagmus is present. Make note of the severity and the direction of the nystagmus.
Figure 1: Head rolled to the right.
Step 4
Guide the patient back into a neutral, supine position.
Step 5
Turn the patient’s head 90 degrees to the opposite side (roll onto the shoulder if necessary) (Figure 2).
Again, observe whether there is nystagmus.
If so, make note of the severity and direction of the nystagmus.
Figure 2: Head rolled to the left.
Step 6
Guide the patient back into a neutral, supine position.
Results
Depending on which side is worse affected, the roll test will generate geotropic nystagmus or apogeotropic nystagmus.
Geotropic nystagmus
Nystagmus is worse on the affected side and beats toward the ground.
Best treated with the Lempert 360-degree roll.
Acceptable alternative treatments are the Gufoni maneuver and forced prolonged positioning.
Apogeotropic nystagmus
Nystagmus is worse on the unaffected side and beats away from the ground.
Best treated by first converting the nystagmus to geotropic and then performing the Lempert 360‑degree roll.
Acceptable alternative treatments are the head thrust test, the Gufoni maneuver, the Vannucchi‑Asprella maneuver, and forced prolonged positioning.
References
Korres S, Balatsouras DG, Kaberos A, Economou C, Kandiloros D, Ferekidis E. Occurrence of semicircular canal involvement in benign paroxysmal positional vertigo. Otol Neurotol. 2002 Nov;23(6):926-32. doi: 10.1097/00129492-200211000-00019. PMID: 12438857.
Gans RE: Evaluating the Dizzy Patient: Establishing Clinical Pathways. Hearing Review 1999; 6 (6): 45-47.
Fife TD. Recognition and management of horizontal canal benign positional vertigo. Am J Otol. 1998 May;19(3):345-51. PMID: 9596187.