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Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Head roll to the right	Head roll to the left

Helpful Hints 

• Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine
• If neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
• It is important to remember that the consistency of fluid inside the vestibular system is relatively viscous; therefore, you should allow sufficient time within each of the positions for the otoconia to achieve maximum displacement. This condition may also be responsible for a delayed onset of nystagmus.
• It is most helpful to utilize Frenzel lenses or VNG when performing positional maneuvers. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight horizontal nystagmus.
• 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
• 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° roll.

Procedure:

• Begin with the patient sitting length-wise on the examination table
• Place the Frenzel/VNG goggles on the patient
• Guide the patient into a supine position. A slight elevation of the head (approximately 20°) is helpful
• Have the patient turn his head 90° to either side. If the patient does not have enough cervical flexibility to provide maximum otoconia displacement, have the patient roll onto his shoulder.
• Carefully observe whether nystagmus is present. Make note of the severity and the direction of the nystagmus.
• Guide the patient back into a neutral, supine position
• Turn the patient’s head 90° to the opposite side (roll onto the shoulder if necessary)
• Again observe whether there is nystagmus; if so, make note of the severity and direction of the nystagmus
• Guide the patient back into a neutral, supine position

Results:

• Geotropic nystagmus - nystagmus is worse on the affected side and beats toward the ground. Best treated with the Lempert 360° 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° roll. Acceptable alternative treatments are head thrust, Gufoni maneuver, Vannucchi-Asprella and forced prolonged positioning.

References:
Korres S and others. Occurrence of semicircular canal involvement in Benign Paroxysmal Positional Vertigo. Otol Neurotol 23:926-932, 2002

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;19:345-351

Vestibular Diagnosis and Treatment
Utilizing Rotary Chair

Purpose of Test:
The purpose of this test is to assess the patient’s Vestibulo-Ocular Reflex (VOR) by rotating the patient in a pendular pattern at various frequencies ranging from 0.01 Hz up to 0.64 Hz with vision denied. This test is considered the “gold standard” test for identifying a bilateral vestibular weakness. The SHA test can also be used to aid in the diagnosis of a unilateral vestibular loss, and can be used to monitor vestibular compensation over time.

Patient Instructions:
“You will feel yourself rocking back and forth slowly in the chair. During the rotation, I will be asking you several questions to keep you alert. Please keep your eyes open during the entire test.”

What to Expect:
A patient with normal SHA results will produce an eye position tracing that shows nystagmus changing from right-beating to left-beating as the chair changes directions. The plotted points in the eye velocity graph will appear to be approximately 180 degrees out of phase from the yellow chair signal trace. The resulting data points for each frequency tested will appear in the Gain, Phase, and Symmetry graphs on the summary screen. These data points will appear in the white region when results are normal and will appear in the shaded region when they are outside of threshold limits. The larger data point denotes which test frequency eye position and eye velocity graphs are currently being displayed. The first half- cycle of each frequency tested is excluded from analysis for improved reliability.

SHA test showing normal responses from 0.01 to 0.32 Hz

Abnormal Test Results:
Abnormal SHA test results may present in several different ways. Reduced VOR gain over a range of test frequencies may indicate that there is a bilaterally weak peripheral vestibular system, provided that technical issues have been accounted for. Please note that phase and symmetry values are of little diagnostic value in the case significantly reduced gains.

A higher than expected phase lead may provide evidence of a disorder affecting the peripheral vestibular system and/or vestibular nerve, or central pathology in rare cases. A decreased phase lead is more often related to central pathology, but may also be observed in the presence of vestibular migraines or motion intolerance.

An asymmetric response is similar to a directional preponderance in caloric testing. An asymmetric SHA response indicates that there is a difference between maximum left-beating and maximum right-beating eye velocity during sinusoidal rotation and provides evidence of a potential unilateral vestibular pathology.

SHA test showing significantly reduced VOR gain across all frequencies

SHA test showing borderline reduced phase across all frequencies

Spectral Purity
In addition to Gain, Phase, and Symmetry, an additional parameter, Spectral Purity, is available in SHA testing. A high percentage of Spectral Purity indicates a more reliable result. The closer the data fits a sine wave, the higher the spectral purity. When spectral purity falls below 60%, it provides evidence that the response may not be of high quality and the clinician should consider retesting that frequency.

SHA test showing poor spectral purity at 0.32 Hz, resulting in erroneous data at that frequency

Conclusion:
SHA testing can be used to identify a bilateral weakness or aid in diagnosis of a unilateral weakness, and allows the clinician to see how the patient’s VOR is performing across multiple frequencies over time. It is a very sensitive test, but is not necessarily a specific test. Therefore, in order to get a more comprehensive look at the vestibular system (lateral semicircular canals), a clinician may choose to perform video head impulse testing (vHIT) or caloric testing along with rotational chair testing.

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

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

Vestibular diagnosis and treatment 

Using EyeSeeCam vHIT to perform Suppression Head IMPulse test 

What is SHIMP
SHIMP stands for Suppression Head IMPulse test. It is used together with conventional Video Head Impulse Test (vHIT), also now referred to as the HIMP or Head IMPulse test. Used along with vHIT, it allows the clinician to determine the extent of vestibular function. In this quick guide we will use the abbreviations vHIT and SHIMP with the understanding that in the literature vHIT is now sometimes referred to as HIMP.

How is the test performed?
For SHIMP, the goggle is placed on the patient’s head in exactly the same way as it is positioned for vHIT. The eye should be centered in the viewing area to ensure that any reflections are beneath the pupil. After adjusting the goggle, centering the laser fixed dots on the wall, and calibrating the head and eye movements, you are ready to perform the SHIMP test. The laser dots will automatically enable when the SHIMP protocol is selected from the session menu.

SHIMPs are performed on the lateral canal by turning the head at least 7 times at high velocities to both the left and right sides. The patient should be instructed to fixate on the center dot generated by the head-fixed laser projected on the wall. The laser dot pattern is the same 5-dot pattern that is used for the calibration process (see the EyeSeeCam manual for details). The appearance of five dots instead of one is not a problem; just ask the patient to focus on the center dot. If you have a wall-fixed target already for vHIT you can begin by aligning the center laser-fixed dot on the same wall-fixed target that you use for the traditional head impulse test.

Starting Position using existing vHIT spot on the wall

1. The first step is to have the patient relax his neck, open his eyes wide and fixate on the center dot in the 5-dot pattern.
2. The second step is to turn the patient’s head either to the right or the left. The 5-dot laser pattern will move with the head so the dots are now located in a new position.
3. The patient is instructed to keep his eyes on the center dot, so when the head moves the eyes should be focused on the newly positioned center dot.

Results
The VOR gains should be similar in vHIT and SHIMP tests. However, the pattern of saccades generated is different. vHIT rarely generates catch-up saccades in healthy patients, while in SHIMP testing, healthy subjects will make a large saccade at the end of the head turn (see figure below). This is referred to as a “SHIMP saccade”. This pattern of result is exactly opposite for impaired patients. An impaired VOR system will lead to a catch-up saccade on the vHIT but no (or very few) SHIMP saccades.

This is an example of healthy subject’s SHIMP results

This is the same patient with results in mirrored view.

When the VOR is impaired the eyes and the target move with the head during head impulses. Therefore, when the SHIMP test is performed on an impaired patient, the eyes always stay on the target, hence no need to make a catch-up saccade. On a healthy subject, when the head is turned (e.g., to the right) the VOR will drive the eyes in the opposite direction (e.g. to the left) and the patient will need to correct for the resulting offset in eye position by making a saccade back to the laser target, hence creating a SHIMP saccade. In an abnormal patient, e.g. someone with an acute unilateral vestibular neuritis, the patient will have no or very few SHIMP saccades for head turns toward the side of lesion.

Summary
Conventional Head Impulse Testing vHIT (or HIMP) is used clinically to identify a deficit in the VOR. When using an earth-fixed target, patients with vestibular losses cannot correct for the head movement so they lose fixation on the target, which results in the patient making a catch- up saccade to return to the target. A healthy person should not lose focus on the earth-fixed target because the VOR keeps the eyes on the target during the head movement. For vHIT, a saccade indicates an impaired vestibular system.

On the other hand, the SHIMP testing is used clinically to provide additional information regarding the VOR function. People with functioning vestibular systems must make a corrective saccade to follow a head-fixed target, while a person with a vestibular loss can follow the target without making a saccade because their eyes move with their head, hence they are always looking at the target. For SHIMPS, a saccade indicates a functioning vestibular system.

It is helpful to use both tests on each patient since they provide complementary results. For e.g. in cases where vHIT is hard to interpret alone (low gain) the SHIMP test can help in determining if the vestibular system is functioning. SHIMPs can also be used for corroborating the level of residual function to help realistic patient expectations before starting rehabilitation.

Vestibular Diagnosis and Treatment
Utilizing Videonystagmography (VNG)

Purpose of Test:
The purpose of caloric irrigation is to identify the degree to which the vestibular system is responsive and also to determine how symmetric the responses are, between left and right. It is a test of the lateral semicircular canals alone -- it does not assess vertical canal function or otolithic function. By using caloric irrigation, you are stimulating each end organ independently of the other to determine whether one end organ is weaker than the other (asymmetry) or whether neither end organ is providing sufficient vestibular information to the brain.

Considerations:

• Pre-test instructions/medications – There is conflicting literature on whether patients should be asked to discontinue central nervous system suppressant medications for 48 hours prior to the VNG. Part of this debate is that patients often don’t understand which medications are allowed and which are not allowed. A general rule of thumb is that the patient should stop taking medications that are prescribed for “dizziness”, but continue to take other medications (such as heart medications, blood pressure medications, etc…).
• A thorough examination of the external ear canal and tympanic membrane is necessary prior to irrigation. The three most important factors to consider are the presence of cerumen, the presence of a tympanic membrane perforation, and the shape of the ear canal. If excessive cerumen is present, it might preclude the stimulus from reaching the inner-most portion of the ear canal and could therefore prohibit a reliable test result. Removal of even the smallest amounts of cerumen is beneficial to the testing process. In the presence of a TM perforation, caloric stimulation by water cannot be completed. Stimulation by air can be performed only briefly to determine whether or a not a vestibular response is present; however, accurate unilateral weakness and directional preponderance measures cannot be calculated. Examination of the shape and curvature of the ear canal is essential to reliable test results for two reasons: (1) Because the irrigator tip is straight and ear canals rarely are, it is not uncommon for the insertion of the irrigator tip to cause slight discomfort to the patient (2) It is important for the stream of air/water from the irrigator to be directed near, but not directly on, the tympanic membrane to avoid injury to the patient. Without a thorough examination of the ear canal, it is impossible to know whether the achieved test results are an accurate assessment of the vestibular system.
• It is necessary to perform VNG with the patient in a vision-denied state to disallow fixation suppression of the nystagmus response
• Alerting tasks are also necessary to discourage the patient from suppressing the nystagmus. The most effective alerting tasks require the patient to use recall memory – i.e. “name a state that begins with the letter ____…” ,“name a color that begins with ___”, “name a city in the state of ________”, etc…
• It is suggested that you begin with warm irrigations (which provide an excitatory response) if for no other reason than if the patient cannot tolerate bi-thermal irrigation, the examiner has AT LEAST enough information to provide a score for the Monothermal Warm Screening Test (MWST).
• MWST is a screening test used mainly for patients who cannot tolerate bi-thermal testing. It is a percentage of asymmetry derived from only the warm-caloric irrigation responses.
• You should wait between 3 and 5 minutes between irrigations, as the nystagmus from the previous test must be completely resolved before you perform the next irrigation. It is suggested that you look at the eyes during the rest periods to watch the nystagmus dissipate. Removal of the mask cover during these rest periods can be helpful to allow the patient to suppress any residual response.
• A “fixation period” of 10 seconds is recommended as a diagnostic tool during the recording of the caloric response (at approximately 90 seconds after the onset of irrigation). The inability to suppress nystagmus when a fixation target is provided is considered a pathological indication of central vestibular pathology.

Patient Instructions:
“I am going to put warm and cool air/water into each ear. I will begin by putting warm air in the right/left ear. The air/water will sound loud and will feel warm, but it should not be painful. If you experience pain, please tell me immediately. The air/water will be in your ear for approximately 60 seconds (30 for water). After 60 (30) seconds, I will take the air/water out of your ear and I will begin to ask you questions. I need two things from you: to keep your eyes open AT ALL TIMES – even if you are feeling “like you are in motion” - and focus on the questions that I am asking you to answer. Do you have any questions before we begin?” It is also helpful to reassure the patient that the sensation of motion is to be expected and will not last very long.

What to Expect:
A fully functional peripheral vestibular end organ will begin to respond to stimulation approximately 15-30 seconds into the irrigation procedure and will reach its peak approximately 60-90 seconds from the beginning of the irrigation process (air stimulus is used in the examples shown here). A rule of thumb is that warm air/water will produce nystagmus that beats toward the test ear and cool air/water will produce nystagmus that beats away from the test ear. (COWS – Cold Opposite, Warm Same). The nystagmus beats are represented by the dots plotted on the graph for each condition. The yellow bar represents the area of maximum performance. Each condition is giving a maximum Slow Phase Velocity (SPV) value and a Fixation Index value (FI). All 4 SPV values are added and a total SPV values is also displayed. The SPV values are used to calculate the overall weakness and to determine if any directional preponderance is present.

COMMON NORMATIVE VALUES FOR CALORIC RESPONSE PARAMETERS

Threshold values for caloric testing, as referenced from Jacobson, GP, and Shepard, NT. Balance Functional Assessment and Management, 2nd Ed. San Diego; Plural Publishing, 2015

Caloric test showing normal response

Abnormal Test Results:
Abnormal caloric test results can present in several ways: as an asymmetry between ears (labeled as “unilateral weakness”), as “directional preponderance” (“directional preponderance” numerically expresses how the amount of right-beating nystagmus compares with the amount of left-beating nystagmus) or as a display of symmetrical, but weak, responses from both ears (labeled as “bilateral weakness”).

Caloric test showing a unilateral weakness (UW)

Caloric test showing a UW, a directional preponderance (DP), and an abnormal fixation value for L44⁰C

Caloric test showing a bilateral weakness (Please note: UW and DP will not be calculated when results present as a bilateral weakness)

Conclusion:
Caloric irrigation is the most valuable tool available to the healthcare field with which to assess vestibular function. It is the only test that allows for evaluation of each peripheral vestibular end organ independently of the other. Caloric irrigation gives the healthcare professional an assessment of whether the peripheral vestibular end organs are functioning symmetrically and/or whether the peripheral vestibular end organs are providing the brain with sufficient sensory information.

For a complete discussion of differential diagnosis using caloric irrigation in VNG, 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.

Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Start with patient sitting up.	Rapidly move to a Side-lying position.
Quickly position head at a 45 degree angle with nose pointing down.

Helpful Hints:

• Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine
• If any neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
• This procedure is an alternative treatment for patients who cannot complete the Lempert 360o Roll, as well as for cases where an apogeotropic lateral canal variant may be present

Procedure:

• Begin with the patient sitting on the edge of the examination table, facing the examiner
• With a rapid motion, guide the patient into a side-lying position toward the affected side
• While the patient is lying on his side, with a quick movement, turn the patient’s head to a 45o angle (so that the patient’s nose is pointing toward the table)
• Hold this position for 2-3 minutes
• Guide the patient back into a sitting position

References:
Gufoni M, Mastrosimone I, DiNasso F. Repositioning maneuver in benign paroxysmal positional vertigo of the horizontal semicircular canal. Acta Otorhinolaryngol Ital 1998;18:363-7

Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otology and Neurology 22:66-69, 2001

Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613.

Vestibular Diagnosis and Treatment
Utilizing Rotary Chair

Purpose of Test:
The purpose of Step Test is to assess the patient’s Vestibulo-Ocular Reflex (VOR) by rotating the patient at an acceleration impulse of 100°/s2 to a fixed chair velocity with vision denied. The time constants, response gain, and time constant asymmetry are then measured. By measuring the vestibular system time constant, both the peripheral vestibular response to the rotational stimulus, as well as the central velocity storage mechanism can be evaluated, making this a useful test for aiding in the diagnosis of a variety of vestibular disorders.

What is a MMN/ P300/?

The mismatch negativity (MMN) response is a negative wave elicited in an ‘oddball’ paradigm where by a deviant stimuli is presented amongst a stream of repeated, or standard, stimuli. The response can be observed by subtracting the responses to the standard stimuli from those of the deviant, and it occurs in the latency region of around 100-300ms. See Fig1, showing an MMN from a 2 kHz deviant tone burst presented amongst a stream of 1 kHz standard tone bursts, measured between vertex and linked- mastoid positions.

Figure 1 MMN response

The P300 response is a positive wave that is also usually elicited in an oddball paradigm. Unlike the MMN, which can be measured without any task requirements, the P300 only occurs when the listener is actively attending to the stimuli. See Fig 2, showing a P300 from a 2 kHz deviant tone burst presented amongst a stream of 1 kHz standard tone bursts, measured between vertex and linked- mastoid positions.

Figure 2 P300 response

Why MMN/P300/?
The MMN and P300 can be used to evaluate higher level auditory function. The MMN test is particularly related to the brain’s ability to discriminate between speech sounds, and its independence of attention may make is suitable for use in evaluating auditory function in various populations in clinical neuroscience and in infants and newborns (Garrido et al., 2009).

How to test
Patient Preparation is very important. Patient arousal and attention state greatly affects the amplitudes of the MMN response, so it is very important that the patient understands the test procedure. The MMN can also be elicited when the subject pays attention to stimuli, but it is difficult to measure in this condition because of the overlapping N2 component. As a result it is recommended to record the MMN while the subject ignores the stimuli. This can be done by letting the subject read or watch a silent captioned video during recording.

The MMN amplitudes decrease with various stages of sleep. It is not advised to perform MMN under sedation.

Electrode Placement:
It is possible to obtain P300/MMN with a standard 2-channel electrode montage, with an active vertex electrode referenced to either right or left mastoid. However, stronger responses can be obtained by linking the right and left mastoids, recording both from the ipsilateral and contralateral side in order to avoid a bias in hemispheric laterality.

Setting up the Eclipse
The Eclipse comes with a pre-programmed protocol for P300/MMN testing (license), ready for immediate use. Protocols can be created or modified easily to fit your clinic needs. Consult your Eclipse Additional Information to learn how to create or modify a protocol.

Protocol settings

• P300/MMN should be measured using toneburst from 250 Hz-4 kHz and custom wave files at an intensity of a moderate levels.
• Custom wavefiles inclusing Da, Ba and Ga are placed on the EPx5 CD-ROM. Please refer to the chapter Importing wavefiles for stimuli in Instruction for Use for guidelines on importing and calibrating custom wavefiles.

Summary of parameters for P300 and MMN

References
Garrido, M. I, Kilner, J.M, Stephan., K.E., and Friston, K.J. (2009) The mismatch negativity: A review of underlying mechanisms. Clinical Neurophysiology 120 453–463.

Hall, J.W. (2007). New Handbook of Auditory Evoked Responses. Pearson
Picton, T. (1992) The P300 wave of the human event-related potential. Journal of Clinical Neurophysiology 9 (4) 456-479.

Vestibular Diagnosis and Treatment

Utilizing Video Head Impulse test (vHIT)

Purpose of test:
To assess the patient’s vestibulo-ocular reflex (VOR) for the Right Anterior and Left Posterior (RALP) semicircular canals. The test allows you to view head and eye movement tracings simultaneously in real time. VOR instantaneous gain and velocity regression are calculated for both Right Anterior and Left Posterior canals during this test.

Calibration
Two calibrations will be completed prior to beginning the test. Standard calibration is completed to calibrate the patient’s eye relative to the laser targets. Place the patient 1.5 meters from the wall on which the laser targets will be projected. Once standard calibration is started, the patient will see 5 red laser dots appear. Instruct the patient to keep his/her head still while moving their eyes between the dots as instructed. Head calibration is completed to calibrate the Inertial Measurement Unit (IMU). With the patient’s eyes fixated on a single target, instruct him/her to gently move the head side to side approximately 5° from center in either direction for 5 seconds. Next, have the patient move the head up and down, following the same procedure.

Beginning the Test:
To begin a RALP test, select RALP from the session menu, click prepare, then start. The impulses will be performed while standing behind the patient with your hands placed on top of the patient’s head. You will be testing in the plane of Right Anterior/Left Posterior canals, as shown below.

Right Anterior	Left Posterior

Patient Instructions:
“I will be moving your head up and down in an angular pattern. Keep your eyes focused on the target on the wall the entire time. Please do not try to resist the head movements, as this will negatively impact the test results. Simply keep your neck loose to allow me to make the small movements.”

Impulse Guide:
A guide is present on the test screen to help you generate RALP impulses of appropriate acceleration and velocity. A green check mark, along with an audible ding, indicates that the impulse was successfully completed and met the criteria to be included in the final report. A red “x” along with audible dong indicates that the impulse did not meet the criteria. The counter next to the test name allows you to view how many accepted impulses have been collected.

In addition, a head detection guide and 3D head model allows you to see whether or not you are moving the patient’s head in the right plane for a RALP test.

RALP head detection guides

What to Expect:
A patient with normal Right Anterior/Left Anterior SSC function will produce eye tracings relative to head tracings that are essentially 180° out of phase, resulting in VOR gain that is near 1.0 for each of the canals tested. Velocity regression should show little to no asymmetry between the two canals tested. There will be no catch-up saccades present in the tracing, as the patient was able to keep his/her eyes fixated on the target during the RALP impulses.

Normal RALP result

Abnormal Test Results:
An “abnormal” RALP result will show reduced gain in one or both of the canals tested. Because the patient was not able to keep his/her eyes fixated on the target during impulses, he/she must produce a “catch-up” saccade to bring the eyes back to the target. Below are examples of “abnormal” RALP tracings:

RALP test showing significantly reduced gain for Left Posterior SSC, with the presence of both covert and overt catch-up saccades.

Conclusion:
RALP vHIT test can be used by the clinician to help determine the presence of Right Anterior/Left Anterior Semicircular Canal dysfunction. RALP vHIT testing should not be relied upon by itself, but rather should be used in conjunction with LARP and Lateral SSC tests, as well as other vestibular tests to diagnose the patient.

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

Vestibular Diagnosis and Treatment
Utilizing Videonystagmography (VNG)

Purpose of Test:
To assess the patient’s ability to maintain a steady gaze on an object at various angles without the eye generating extraneous movements (i.e. square wave jerks or nystagmus). The inability to maintain a steady gaze is an indication of either a central or peripheral vestibular system lesion. Gaze positions tested are: center (straight ahead), gaze left, gaze right, gaze up and gaze down.

Patient Instructions:
“You will see a green dot on the screen. Simply look at the dot. If the dot moves, follow it with your eyes only. Try not to move your head.”

What to Expect:
A patient with normal gaze ability will produce a tracing that is virtually a straight line once the eyes are fixated on the target. The right eye is represented by the red line and the left eye by the blue line. If nystagmus is present it will be identified by triangles on the eye position graph to represent each detected nystagmus beat. The average slow phase velocity value(s) will be plotted in the bar graphs to the right of the tracings. When the average slow phase velocity exceeds the threshold value of 6⁰/sec, the bar graph will be shaded grey and a red diamond will appear near the bar graph to indicate an out of threshold response.

Gaze test showing normal response for all gaze angles (center, left, right, up and down)

Abnormal Test Results:
An “abnormal” gaze tracing might present itself in several ways. A patient may present with square wave jerks, nystagmus, or gaze decay. Below are examples of abnormal tracings:

Gaze test showing bilateral gaze-evoked nystagmus

Gaze test showing down-beating nystagmus on gaze down 20⁰

Conclusion:
Gaze testing is the ONLY test of the four ocular tests in which an “abnormal” result could be generated either from the peripheral vestibular system or from the central vestibular system.

For a complete discussion of differential diagnosis using the gaze stability test, 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.

Vestibular Diagnosis and Treatment

Utilizing Video Head Impulse test (vHIT)

Purpose of test: 
To assess the patient’s vestibulo-ocular reflex (VOR) for the Left Anterior and Right Posterior (RALP) semicircular canals. The test allows you to view head and eye movement tracings simultaneously in real time. VOR instantaneous gain and velocity regression are calculated for both Left Anterior and Right Posterior canals during this test.

Calibration:
Two calibrations will be completed prior to beginning the test. Standard calibration is completed to calibrate the patient’s eye relative to the laser targets. Place the patient 1.5 meters from the wall on which the laser targets will be projected. Once standard calibration is started, the patient will see 5 red laser dots appear. Instruct the patient to keep his/her head still while moving their eyes between the dots as instructed. Head calibration is completed to calibrate the Inertial Measurement Unit (IMU). With the patient’s eyes fixated on a single target, instruct him/her to gently move the head side to side approximately 5° from center in either direction for 5 seconds. Next, have the patient move the head up and down, following the same procedure.

Beginning the Test:
To begin a LARP test, select LARP from the session menu, click prepare, then start. The impulses will be performed while standing behind the patient with your hands placed on top of the patient’s head. You will be testing in the plane of Left Anterior/Right Posterior canals, as shown below.

Patient Instructions:
“I will be moving your head up and down in an angular pattern. Keep your eyes focused on the target on the wall the entire time. Please do not try to resist the head movements, as this will negatively impact the test results. Simply keep your neck loose to allow me to make the small movements.”

Impulse Guides:
A guide is present on the test screen to help you generate LARP impulses of appropriate acceleration and velocity. A green check mark, along with an audible ding, indicates that the impulse was successfully completed and met the criteria to be included in the final report. A red “x” along with audible dong indicates that the impulse did not meet the criteria and will not be allowed into the final report. The counter next to test name allows you to view how many accepted impulses have been collected.

In addition, a head detection guide and 3D head model allows you to see whether or not you are moving the patient’s head in the right plane for a LARP test.

LARP head detection guides

What to Expect:
A patient with normal Left Anterior/Right Posterior SSC function will produce eye tracings relative to head tracings that are essentially 180° out of phase, resulting in VOR gain that is near 1.0 for each of the SCCs tested. Velocity regression should show little to no asymmetry between the two canals tested. There will be no catch-up saccades present in the tracing, as the patient was able to keep their eyes fixated on the target during the LARP impulses.

Normal LARP Result

Abnormal Test Results:
An “abnormal” LARP result will show reduced gain in one or both of the canals tested. Because the patient was not able to keep his/her eyes fixated on the target during impulses, he/she must produce a “catch-up” saccade to bring the eyes back to the target. Below are examples of “abnormal” LARP tracings:

LARP test showing Right Posterior SCC gain reduction with the presence of covert catch-up saccades in a patient with right-side vestibular neuritis.

Conclusion:
LARP vHIT test can be used by the clinician to help determine the presence of Left Anterior/Right Posterior Semicircular Canal dysfunction. LARP vHIT testing should not be relied upon by itself, but rather should be used in conjunction with RALP and Lateral SSC tests, as well as other vestibular tests to diagnose the patient.

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

Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Treatment of the left horizontal canal:

Roll the patient's body toward the unaffected side.	Roll the patient into the prone position.
Roll the patient's body toward the affected side.

Helpful Hints:

• Utilizing Video Frenzel or VNG while performing this maneuver is recommended to reduce the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight horizontal nystagmus. If the treatment is successful, the nystagmus will beat in the same direction throughout the procedure.
• The success rate of this procedure in the treatment of horizontal canal BPPV is very high and success is usually immediate. If the procedure is successful, the patient may not exhibit symptoms during the last steps of the procedure.
• If the patient does not show marked improvement upon completion of the procedure, you should repeat the procedure. If there is still no improvement, it is possible that the wrong ear has been treated.
• It is important that the patient maintain the 20° head position to prevent the otoconia from reversing direction within the horizontal canal during the procedure
• Refer to attached chart for specific details regarding diagnosis and treatment of each nystagmus condition
• The patient’s compliant will often be that he/she experiences “dizziness” when turning his/her head in bed without turning the body

Procedure:

• Begin by having the patient lay in supine position with the head elevated at approximately 20o
• Roll the patient onto the shoulder of the unaffected side
• Hold this position for 30-60 seconds
• Roll the patient into the prone position maintaining the 20° head position (this will require the patient to hang their head off the table as illustrated)
• Hold this position for 30-60 seconds
• Next, roll the patient onto their affected side while maintaining the 20° head position
• Hold this position for 30-60 seconds
• Guide the patient back into a sitting position

Right Geotropic Horizontal Canal BPPV
SYMPTOM: Nystagmus is greater when affected (right) ear is in the downward position
TREATMENT: Lempert 360° roll to the LEFT
NYSTAGMUS: Should beat toward the LEFT throughout the entire procedure
IMPLICATION: Pathological localization is generally in the utricle of the affected ear

Left Geotropic Horizontal Canal BPPV
SYMPTOM: Nystagmus is greater when affected (left) ear is in the downward position
TREATMENT: Lempert 360° roll to the RIGHT
NYSTAGMUS: Should beat toward the RIGHT throughout the entire procedure
IMPLICATION: Pathological localization is likely in the utricle of the affected ear

Right Apogeotropic Horizontal Canal BPPV
SYMPTOM: Nystagmus is greater when affected (right) ear is in the upward position
TREATMENT: Convert nystagmus from apogeotropic to geotropic by using one of the methods listed below
IMPLICATION: Pathological localization is likely in the horizontal canal of the affected ear

Left Apogeotropic Horizontal Canal BPPV
SYMPTOM: Nystagmus is greater when affected (left) ear is in the upward position
TREATMENT: Convert nystagmus from apogeotropic to geotropic by using one of the methods listed below
IMPLICATION: Pathological localization is likely in the horizontal canal of the affected ear

Conversion Methods for Apogeotropic Horizontal Canal BPPV

• Head Thrust
• Modified Guffoni
• Vannucchi -Asprella
• Forced Prolonged Positioning

References:
Lempert T, Tiel-Wilck K. A positional maneuver for treatment of horizontal canal benign positional vertigo. Laryngoscope 1996;106:476-478

Fife TD. Recognition and management of horizontal canal benign positional vertigo. Am J Otol. 1998;19(3):345-351

Tirelli G, Russolo M. 360-Degree canalith repositioning procedure for the horizontal canal. Otolaryngol Head Neck Surg. 2004 Nov;131(5):740-6 

Vestibular Diagnosis and Treatment

Utilizing Video Head Impulse test (vHIT)

Purpose of test:
To assess the patient’s vestibulo-ocular reflex (VOR) for the Left and Right Lateral Semicircular Canals (SCC). The test allows you to view head and eye movement tracings simultaneously in real time. VOR instantaneous gain and velocity regression are calculated for both Left Lateral and Right Lateral canals during this test.

Calibration:
Two calibrations will be completed prior to beginning the test. Standard calibration is completed to calibrate the patient’s eye relative to the laser targets. Place the patient 1.5 meters from the wall on which the laser targets will be projected. Once standard calibration is started, the patient will see 5 red laser dots appear. Instruct the patient to keep his/her head still while moving their eyes between the dots as instructed. Head calibration is completed to calibrate the Inertial Measurement Unit (IMU). With the patient’s eyes fixated on a single target, instruct him/her to gently move the head side to side approximately 5° from center in either direction for 5 seconds. Next, have the patient move the head up and down, following the same procedure.

Beginning the Test:
To begin a lateral vHIT test, select lateral from the session menu, click prepare, then start. The impulses will be performed while standing behind the patient with your hands placed beneath the goggle strap around the patient’s jaw. You will be testing in the plane of Left Lateral/Right Lateral canals, as shown below.

Patient Instructions:
“I will be moving your head side to side in small movements. Keep your eyes focused on the target on the wall the entire time. Please do not try to resist the head movements, as this will negatively impact the test results. Simply keep your neck loose to allow me to perform the small movements.”

Impulse Guide:
A guide is present on the test screen to help you generate lateral impulses of appropriate acceleration and velocity. A green check mark indicates that the impulse was successfully completed and met the criteria to be included in the final report. A red “x” indicates that the impulse did not meet the criteria and will not be allowed into the final report. The counter next to test name allows you to view how many accepted impulses have been collected.

What to Expect:
A patient with normal Left and Right SSC function will produce eye tracings relative to head tracings that are essentially 180° out of phase, resulting in VOR gain that is near 1.0 for each of the SCCs tested. Velocity regression should show little to no asymmetry between the two canals tested. There will be no catch-up saccades present in the tracing, as the patient was able to keep their eyes fixated on the target during the lateral impulses.

Normal Lateral Test Result

Abnormal Test Results:
An “abnormal” lateral result will show reduced gain in one or both of the canals tested. Because the patient was not able to keep his/her eyes fixated on the target during impulses, he/she must produce a “catch-up” saccade to bring the eyes back to the target. Below are examples of “abnormal” lateral vHIT tracings:

Lateral vHIT test showing a Left Lateral Canal weakness in an acute stage of neuritis

Lateral vHIT test showing a bilateral asymmetrical lateral canal weakness in a cochlear impatient patient

Conclusion:
Lateral vHIT test can be used by the clinician to help determine the presence of Left/Right Semicircular Canal dysfunction. Lateral vHIT testing should not be relied upon by itself, but rather should be used in conjunction with RALP and LARPl SSC tests, as well as other vestibular tests to diagnose the patient.

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

Vestibular Diagnosis and Treatment
Utilizing Rotary Chair

Purpose of Test:
To assess the patient’s ability to suppress the Vestibulo-Ocular Reflex (VOR) while rotating. The patient is rotated in a pendular pattern at various frequencies ranging from 0.04 Hz up to 0.32 Hz while focusing on a fixation light within the enclosed goggles. By comparing the patient’s vision-denied SHA results to the VOR suppression results at the same frequency of rotation, a percentage of gain reduction can be calculated.

Patient Instructions:
“You will feel yourself rocking back and forth slowly in the chair. During the rotation, you will see a small green light appear within the mask (sometimes you may see more than one light, that is ok, just choose one light and focus on it). Please keep your eyes open and focused on the green light during the entire test. Try to prevent the light from ‘bouncing’ around in your view.”

What to Expect:
A patient with normal VOR suppression results will produce a tracing that shows significantly reduced nystagmus as the patient is rotated sinusoidally from left to right in the chair. The data points for each frequency tested will appear as triangles in the Gain (%) and Reduction (%) graphs above the eye position (°) and eye velocity (°/s) graphs on the summary screen.. The circular data points represent the previously recorded SHA results at the same frequency of rotation. The green data point denotes which frequency tracing is currently being displayed. Triangles that appear in the white region in the Reduction (%) graph represent a normal response. Triangles that appear in the shaded region indicate that the data falls outside of threshold limits. The first half-cycle of each frequency tested is excluded from analysis for improved reliability.

VOR Suppression test showing a normal response

Abnormal Test Results:
A failure to sufficiently suppress the VOR can be an indicator of possible central pathology.

VOR Suppression test showing an abnormal reduction percentage at 0.32 Hz

Conclusion:
VOR Suppression testing can be used to test the central vestibular pathways and allows the clinician to see the patient’s VOR suppression performance across multiple Sinusoidal Harmonic Acceleration frequencies, typically above 0.04 Hz.

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

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

Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Dix-Hallpike test performed to the right:

Begin with patient seated, wearing goggles, with head turned 45° to the right	Quickly lie the patient back with head turned 45° and hanging approximately 20°

Dix-Hallpike test performed to the left:

Begin with patient seated, wearing goggles, with head turned 45° to the left	Quickly lie the patient back with head turned 45° and hanging approximately 20°

Precautions:

• Before performing any positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine
• If neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
• It is important to remember that the consistency of fluid inside the vestibular system is relatively viscous; therefore, you should allow sufficient time within each of the Dix-Hallpike maneuvers for the otoconia to achieve maximum displacement. This condition may also be responsible for a delayed onset of nystagmus.
• It is most helpful to utilize Frenzel lenses or VNG while performing the Dix-Hallpike test. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight torsional nystagmus.
• It is not unusual for the patient to lose postural control at the completion of the procedure due to the otoconia briskly falling within the cupula. It is vital that the examiner is in a stance that will provide the patient with postural support in this situation.
• It is common for the patient to tell you during the intake interview which ear is affected and to 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

Procedure

• Begin with the patient sitting length-wise on the examination table
• Place the Frenzel/VNG goggles on the patient
• Have the patient turn his head to a 45° angle toward the side that you suspect to be affected (the affected side)
• While maintaining the 45° head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20°. IT IS IMPERATIVE TO PROVIDE CERVIAL SUPPORT DURING THIS PORTION OF THE PROCEDURE.
• Hold this position for 30-60 seconds or until nystagmus has subsided
• Guide the patient back into a sitting position
• Allow 30-60 seconds in the sitting position to allow for the patient to recover
• Have the patient turn his head 90° toward the unaffected side, so that the head is at a 45° angle toward the unaffected side
• While maintaining the 45° head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20°. IT IS IMPERATIVE TO PROVIDE CERVIAL SUPPORT DURING THIS PORTION OF THE PROCEDURE.
• Hold this position for 30-60 seconds or until nystagmus has subsided
• Guide the patient back into a sitting position
• Maintain postural support until the patient is physically stable

References:

• Dix MR, Hallpike CS.Pathology ,symptoms and diagnosis of certain disorders of the vestibular system. Proc R Soc Med. 1952;45:341-354
• Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613.

Dix-Hallpike - Test for Diagnosis of BPPV

Posterior Canalithiasis

• Perception of vertigo often occurs in conjunction with the nystagmus
• Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side)
• Recommended treatment is the Epley Maneuver of the affected side
• Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises

Posterior Cupulothiasis

• Perception of vertigo may subside even though nystagmus is still present
• Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side)
• Recommended treatment is the Semont Liberatory Maneuver
• An alternative treatment is Brandt-Daroff Exercises

Anterior Canalathiasis

• Perception of vertigo often occurs in conjunction with the nystagmus
• Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side)
• Recommended treatment is the Epley CRP
• Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises

Anterior Cupulothiasis

• Perception of vertigo may subside even though nystagmus is still present
• Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side)
• Recommended treatment is the Semont Liberatory Maneuver
• An alternative treatment is Brandt-Daroff Exercises

Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Treatment of the left anterior canal:

Turn the head 45° to the left side.	Rapidly move into side-lying position on the affected side.	Rapidly move to patients unaffected side with the nose 45° upward.

Helpful Hints:

• Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine
• If any neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
• The patient should experience vertigo when moved to the face-down position. If not, it is often useful to perform a slight headshake in an effort to loosen otolithic debris.

Procedure:

• Begin with the patient sitting on the examination table, facing the examiner, with the patient’s head turned toward the affected side at a 45° angle
• Guide the patient into a side-lying position on the affected side. (This should be a rapid movement and the patient’s nose should be pointing downward.)
• Hold this position for 2-3 minutes
• While maintaining the 45o head position, guide the patient in a continuous motion from side-lying on the affected side to side-lying on the unaffected side. (The patient’s nose should be pointing upward.)
• Hold this position for 3-5 minutes
• Guide the patient back into a sitting position

References:
Semont, Freyss G, Vitte E. Curing the BPPV with a liberative maneuver. Adv Otorhinolaryngol. 1998;42:290-3

Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613

With assistance

Without assistance

Helpful Hints:

• Before recommending any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine
• If possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
• In order for the exercise to be successful, the patient MUST remain in each position until the vertigo subsides PLUS an additional 30 seconds and the patient must perform all 10 revolutions of the exercise. This is time consuming and often traumatic for the patient due to intense vertigo. Therefore, it is vital that the patient is educated on what to expect during the exercise and has agreed to full compliance.
• Without the patient’s commitment to full compliance, performing the Brandt-Daroff exercises might actually be counter-productive in that otoconia may travel to different parts of the vestibular system and cause a worsening of symptoms.
• You should instruct the patient that if they are doing the exercise properly, their symptoms will likely lessen in severity with each repetition. However, they should always do the full set of 10 complete revolutions

Procedure:

• Begin with the patient sitting on his bed
• The patient will turn his head 45o toward either side
• The patient moves from sitting position to side-lying position while maintaining the 45o angle of the head (the patient’s nose should be pointed upward)
• The patient lies in this position until his symptoms have subsided PLUS an additional 30 seconds
• The patient returns to the sitting position and waits for symptoms to subside PLUS an additional 30 seconds
• The patient should turn his head in the opposite direction and repeat the exercise

** The above description constitutes one revolution of the exercise. It is recommended that the patient perform ten complete revolutions of the exercise, three times daily.

References:
Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980 Aug;106(8):484-485

Fife TD, et al.(2008). Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70(22): 2067–2074.

Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Treatment of the left posterior canal:

Turn the head 45° to the right side.	Rapidly move into side-lying position on the affected side.	Rapidly move to patients unaffected side with the nose 45° down.

Helpful Hints:

• Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine.
• If any possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
• The patient should experience vertigo when moved to each position. If not, it is often useful to perform a slight headshake in an effort to loosen otolithic debris.

Procedure:

• Begin with the patient sitting on the examination table, facing the examiner, with the patient’s head turned away from the affected side at a 45° angle
• Guide the patient into a side-lying position toward the affected side. (This should be a rapid movement and the patient’s nose should be pointing upward.)
• Hold this position for 2-3 minutes
• While maintaining the 45° head position, guide the patient in a continuous motion from side-lying on the affected side to side-lying on the unaffected side. (The patient’s nose should be pointing downward toward the table.)
• Hold this position for 3-5 minutes
• Guide the patient back into a sitting position

References:
Semont, Freyss G, Vitte E. Curing the BPPV with a liberative maneuver. Adv Otorhinolaryngol. 1998;42:290-3

Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613 

Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Treatment of the right anterior canal:

Turn the head 45° to the right side.	Rapidly move into side-lying position on the affected side.	Rapidly move to patients unaffected side with the nose 45° upward.

Helpful Hints:

• Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine.
• If neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
• The patient should experience vertigo when moved to the face-down position. If not, it is often useful to perform a slight headshake in an effort to loosen otolithic debris.

Procedure:

• Begin with the patient sitting toward the side of the examination table with the patient’s head turned toward the affected side at a 45° angle
• Guide the patient into a side-lying position toward the affected side. (This should be a rapid movement and the patient’s nose should be pointing downward.)
• Hold this position for 2-3 minutes
• While maintaining the 45° head position, guide the patient in a continuous motion from side-lying on the affected side to side-lying on the unaffected side. (The patient’s nose should be pointing upward.)
• Hold this position for 3-5 minutes
• Guide the patient back into a sitting position

References:
Semont, Freyss G, Vitte E. Curing the BPPV with a liberative maneuver. Adv Otorhinolaryngol. 1998;42:290-3

Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613

Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Treatment of the right posterior canal:

Turn the head 45° to the left side.	Rapidly move into side-lying position on the affected side.	Rapidly move to patients unaffected side with the nose 45° down.

Helpful Hints:

• Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine
• If any neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
• The patient should experience vertigo when moved to each position. If not, it is often useful to perform a slight headshake in an effort to loosen otolithic debris.

Procedure:

• Begin with the patient sitting on the examination table, facing the examiner, with the patient’s head turned away from the affected side at a 45° angle
• Guide the patient into a side-lying position toward the affected side. (This should be a rapid movement and the patient’s nose should be pointing upward.)
• Hold this position for 2-3 minutes
• While maintaining the 45° head position, guide the patient in a continuous motion from side-lying on the affected side to side-lying on the unaffected side. (The patient’s nose should be pointing downward toward the table.)
• Hold this position for 3-5 minutes
• Guide the patient back into a sitting position

References
Semont, Freyss G, Vitte E. Curing the BPPV with a liberative maneuver. Adv Otorhinolaryngol. 1998;42:290-3

Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613

Vestibular Diagnosis and Treatment
A Physical Therapy Approach

Epley Maneuver for right posterior canal BPPV: 

Begin with the patient’s head turned 45 degrees toward the affected side.	Bring to a supine position with the head turned toward the affected side and hanging 20°.
Rotate the patient’s head 90 degrees toward the unaffected side.	Guide the patient to the side lying position with their nose pointing to the ground.
While keeping the head in 45°, tucked position, return the patient to a seated position.

Helpful Hints:

• It is most helpful to utilize Frenzel lenses or VNG while performing CRP. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight torsional nystagmus.
• Before performing any positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine
• If neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion.
• Efficacy of the procedure is increased to >90% if CRP is performed twice in rapid succession
• It is not unusual for the patient to lose postural control at the completion of the procedure due to the otoconia briskly falling within the cupula. It is vital that the examiner is in a stance that will provide postural support to the patient.
• It is important to watch for changes in the nystagmus upon completion of the procedure: a reversal of nystagmus indicates that the otoconia fell back into the canal; an upbeat nystagmus indicates that the otoconia fell back into the cupula.

Procedure:

• Begin with the patient sitting length-wise on the examination table
• Place the Frenzel/VNG goggles on the patient
• Have the patient turn his head to a 45o angle toward the side that you are going to treat (the affected side)
• While maintaining the 45o head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20o. IT IS IMPERATIVE TO PROVIDE CERVIAL SUPPORT DURING THIS PORTION OF THE PROCEDURE.
• Hold this position for 30-60 seconds
• Maintain the 20o head extension and rotate the patient’s head 90o toward the unaffected side so that the patient’s head is approximately 45o toward the unaffected side
• Hold this position for 30-60 seconds
• While still maintaining the 45o head position, guide the patient into a side-lying position on the shoulder of the unaffected side. The patient’s nose should be pointed toward the floor.
• Hold this position for 30-60 seconds
• Instruct the patient to tuck his chin and maintain the 45o head position
• Guide the patient back into a sitting position while ensuring that the patient’s head remains at the 45o angle and the chin remains tucked

**Refer to the attachment in attempting to diagnose affected ear and canal.

References:

• Epley J. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404
• Honrubia V, Baloh RW, Harris MR, et al. Paroxysmal positional vertigo syndrome. Am J Otol. 1999;20:465-470
• Sherman D, Massoud EA. Treatment outcomes of benign paroxysmal positional vertigo. J Otolaryngol 2001;30:295-299.

CRP in the Treatment of BPPV

Posterior Canalithiasis:

• Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side) that is less than one minute in duration
• Recommended treatment is the Epley Maneuver of the affected side
• Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises

Posterior Cupulothiasis:

• Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side) that is greater than one minute in duration
• Recommended treatment is the Semont Liberatory Maneuver
• Alternative treatments might include Brandt-Daroff Exercises or the Epley CRP

Anterior Canalathiasis:

• Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side) that is less than one minute in duration
• Recommended treatment is the Epley CRP performed on the opposite side of the affected ear
• Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises

Anterior Cupulothiasis:

• Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side) that is greater than one minute in duration
• Recommended treatment is the Semont Liberatory Maneuver
• Alternative treatments might include Brandt-Daroff Exercises or the Epley CRP