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Dix-Hallpike Test for Diagnosis of BPPV

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
March 2017
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