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Ralp Test - Utilizing Video Head Impulse Test (vHIT)

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.

December 2016
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