Vestibular Tests & Measures: Study Guide

Nystagmus is described by the direction of the Directions to perform TEST Positive sign Central vs.
quick phase. demonstrated by Peripheral
Rotary / Torsional N. is described by the direction
that the superior pole of the iris moves, L or R.
Eye Movement Range Take your finger out past 18-24” to examine if the patient has full
ocular range of motion. Ask the patient to follow a moving object
(your finger) that is held several feet in front of the patient’s face
(to avoid convergence of eyes.)

Smooth pursuit Maintains gaze Hold the patient’s head stationary. Have the patient follow your Consistent saccades Central
stabilization when slowly moving finger horizontally (from center to 30 degrees right on repetition of test
rate of eye and then to 30 degrees left), and then vertically (center to 30 directions.
movement is degrees up to 30 degrees down). Can use an “H” pattern. The test
< 60d/sec, i.e. can be repeated; you may have to hold the eyelids up in order to see Nystagmus: quick
slower then VOR the downward eye movement clearly. phase AWAY from
Gain testing lesion side
End point Nystagmus During maintenance of an extreme eye position. Head fixed. Eyes 1-2 beats is normal.
(normal response) follow my finger and then held at the end point. (all 4 directions).

Gaze evoked Hold the patient’s head stationary. Have the patient follow your Nystagmus not Central or
Nystagmus finger so she/he is looking 30 degrees to the right, left, up, down. normal if lasts > 5 Cranial III, IV,
(abnormal response) Pause for 20 seconds in each of those positions to observe for sec. VI
nystagmus. Note the direction of the nystagmus in each position.
Be sure to keep your finger 18-24 inches away from the patient’s
face throughout the entire test.

Saccades a. Extra involuntary eye movements during tracking. Saccades can be Central
b. Normal saccadic movement: continue to hold the patient’s head normal when
stationary. Hold your finger about 15 degrees to one side of smooth pursuit
your nose. Ask the patient to look at your nose, then at your motion is very fast
finger, repeating several times. Do this from the right, left, up,
and down. You are looking for the number of eye movements it
takes for the patient’s eyes to reach the target. Normal is <2.
Diplopia Patient report. Lasting > 2 weeks Central: rule out
MS, TBI
Oscillopsia: visual Decreased VOR Patient report (see also Dynamic Visual Acuity Test) Peripheral or
blurring with head gaze stability with Central
movement head motion May also be reported as “seaweed” movement without head mvmt.
Skew deviation Therapist alternately covers and uncovers each eye, while patient Vertical Brainstem, also
keeps their eyes open. Look for misalignment and dropping of the misalignment utricle
Cover Cross Cover eye after cover is removed. A vertical misalignment (skew dysfunction.
Test deviation) can be indicative of otolith imbalance on the side where
the eye was too low or indicative of a central brainstem lesion.
Ocular Tilt Reaction Observation: Triad = head tilt + skew deviation + torsion Unilateral
OTR See illustration on: O’Sullivan 4th ed. p.832 brainstem
(can accompany O’Sullivan 5th ed. p.1013 Medullary
Wallenberg syndrome) infarct
Subjective Visual Equipment: 5 gallon bucket with a straight line drawn across the Abnormal if > 2 Utricle function
Vertical (SVV) bottom of the bucket (inside and outside). degrees off
Task: with their head “inside” the bucket, the patient turns the
bucket so that they perceive the line to be vertical. Then horizontal
Spontaneous Holding the patient’s head with one hand. Have the patient look
nystagmus straight ahead and observe for nystagmus (slow phase/fast phase).
(not movement or
position related) Horizontal Nystagmus that stops w gaze fixation = Peripheral
Nystagmus that does NOT stop with gaze fixation = Central
Optokinetic nystagmus If you have access to an optokinetic drum, have the patient follow
the striped lines with their eyes while you slowly move the drum in
(normal physiological one direction. Repeat this procedure rotating the drum in the
occurrence of opposite direction. You should observe for optokinetic nystagmus
nystagmus under these (slow phase eye movements in the direction of drum rotation). Be
conditions) careful to not rotate the drum too quickly. You should note if the
patient does not produce slow phase eye movements or if the slow
phase eye movements are saccadic in nature. Additionally, you
should note the direction of drum movement in which this occurs.

VOR Gain Maintains fixed “Keep your eyes on my finger.” Dizziness, Vestibular
1. Maintained Fixation gaze with head “Move your head to the left … right … up … down” excessive saccades hypofunction
movement (eyes Done at a rate of > 60d / sec. (faster than smooth pursuit)
move opposite to e.g. VOR x 1
head).
VOR Faster and harder to The patient will need to understand what will be done so their neck Saccade (to catch Peripheral:
2. Head Thrust Test. perform than the is relaxed during the test. If you noted that the patient had pain or up) UVL, BVL
(eyes open: EO) test of VOR significant restriction in cervical spine mobility, this test should be L sided thrust yields
Tilt head 30d down. Maintained Fixation performed with extreme caution or should be deferred. saccade? = L lesion

Grasp the patient’s head firmly with both hands on the side of their Helpful to
head. Tilt their head forward 30 so that horizontal semi-circular differentiate L / R
canals are level in the horizontal plane. Instruct the patient to look
at your nose. Move the patient’s head slowly back and forth being
sure the patient is relaxed. Then, suddenly move the patient’s head
in one direction and stop. The head movement should be moved
through a small amplitude with the position held at the end.
Observe for the patient’s ability to maintain visual fixation. You
should note if the patient makes corrective saccades to re-fixate on
your nose and the direction of head movement that caused the re-
fixation saccades, e.g. if a thrust to the L yields a saccade to re-
fixate on your nose a Left UVL is indicated.
Note: If you are uncomfortable moving the person’s head from
 center to an eccentric position, try moving the person’s head from
an eccentric position to center
VOR Eyes are closed and with 30º neck flexion (horizontal SCC Horiz. Nystagmus = Peripheral UVL
3. Head Shaking position). I shake their head vigorously (2 Hz) L&R for 20 cycles. Vertical Nystagmus = Central
Induced Nystagmus. Stop and then they open their eyes (best viewed with frenzels).
(eyes closed – EC)
Tilt head 30d down.
VOR Therapist holds target in front of subject at eye level. Ask subject to Saccades, Central:
4. VOR Cancellation move head and eyes to follow the target as the therapist moves the Nystagmus, Cerebellar
target slowly side to side, up and down, and in diagonals. The arc Difficulty crossing
Cerebellum has to of movement should be within 30° of the midline in all directions. midline.
inhibit the VOR Gain
during VOR
Cancellation
VOR Passive Test Have the patient wear their glasses if they need distance correction. Horiz. SCC
5. Dynamic Visual Depending on the type of acuity chart being utilized, have the
Acuity Test – DVA patient sit the appropriate distance from the chart. (The ETDRS
Tilt head 30d down. charts are designed to be viewed from a distance of 4 meters to
provide Snellen equivalent acuity ratios or LogMAR values as
noted on the chart). Have the patient read to the lowest line that
they can until they cannot correctly identify all the letters on a
given line. Note the line where this occurs and/or the number of
optotypes the patient incorrectly identifies.

Now, standing behind the patient, grasp the patient’s head firmly
with both hands on the side of their head, tilt their head forward 30
so that horizontal semi-circular canals are level in the horizontal
plane. While moving their head side to side at a frequency of 2 Hz
(2 complete side to side cycles per second – use metronome set at
200-240 bpm) have the patient read to the lowest line that they can
until they can not correctly identify all the letters on a given line.
Note the line where this occurs and/or the number of optotypes the
patient incorrectly identifies. Keep the range of motion of the head
movements small so as to not restrict the visual field, which may
occur with patients who wear glasses.

If “lose” >2 lines compared to static = oscillopsia.

If lose >3 lines = Vestibular hypofunction.
Positional Maneuvers (Assessment)
1. Hallpike-Dix Test Test of Posterior Criteria for positive HPD sign: (example below is for R side lesion) Vertigo, Peripheral:
and Anterior SCC 1. torsional/linear-rotary nystagmus; reproduced by provocative Nystagmus: misplaced or
(test unaffected side positioning with affected R ear down  < 60s adhered otoconia
first, if obvious from + Post. SCC sign will 2. brief latency of 5-15 seconds before the start of nystagmus. Canalithiasis
be Upbeating (cranial)  > 60s:
history) 3. nystagmus of brief duration, (toward the lesion i.e. R torsion)
nystagmus (63%) Cupulolithiasis
4. reversal of nystagmus direction on return to upright position (fatigues)
+ Ant. SCC sign will
 be Downbeating (away from lesion i.e. L torsion)  Persistent:
(caudal) nystagmus 5. response diminishes with repetition of maneuver (fatigability) possibly Central

2. Roll Test Test of Horizontal Supine, position head in 20d of flexion. Turn head 90d to one side. Peripheral:
SCC (15%) Maintain for 1 min. Return head to midline. Repeat to opposite misplaced or
(See O’Sullivan 5th ed. p.1010) adhered otoconia
side. Will be positive to both sides, with one side being worse.

 Geotropic Nystagmus = Canalithiasis  Horizontal CRT

 Ageotropic Nystamus = Cupulolithiasis  Brandt Daroff
3. Vertebral Art. Test  Maneuver: Sit with knees on elbows and chin in hand. Look Vertigo, nystagmus,
up to the (right) for 30 seconds. headache, visual
 Maneuver: Sitting with (passive) cervical extension and disturbance central
rotation, holding 30 sec. (Magee p.154) signs.
Functional Tests
Motion Sensitivity Instruments:
Motion Sensitivity Score (Vestibular System Evaluation & Training): rolling, sit to stand, etc. (16 items), with
vertigo rated for duration and intensity.
Balance & Mobility Instruments: Questionnaires:
 Functional Reach, Multidimensional Reach  Dizziness Handicap Inventory
 Berg Balance  Modified Falls Efficacy Scale
 Tinetti Balance & Gait  Activities-specific Balance
 TUG, and the Five-Times Sit to Stand Confidence (ABC) Scale
 Preferred Gait Speed  Physical Activity Scale for the
 Functional Gait Assessment, and 4-item Dynamic Gait Index Elderly (PASE)
 Fukuda  Cognition:
 Perturbation Tests (hips, sternum) o Mini Mental State Exam
 Clinical Test of Sensory Integration and Balance (CTSIB) o Blessed Orientation-
Memory-Concentration Test
o Geriatric Depression Scale
Portions adapted from Herdman SJ. Vestibular Testing & Rehabilitation Competency Course, Notes, Emory University & APTA. March, 2004. Abbott C, Prost E. Aug. 12, 2014.
Eppley Maneuver: Canalith Repositioning Treatment for Canalithiasis (example below is to treat a right BPPV)
1. Patient is positioned in long sitting, with head turned 45d toward the affected ear (positive HPD side) e.g. to the right.
2. Rapidly bring the person back into supine with head hanging over the end of table (same as HPD position).
3. Wait for S&S to subside, and then wait an additional 30 sec.
4. Slowly rotate head to the opposite side (left), while keeping the neck in extension. Wait 30 seconds.
5. Ask the person to log roll onto their (left) side, (their head will now be turned nearly face down). Wait 30 seconds.
6. Then have the person push up to sitting, while still keeping their head turned to the left. Continue to observe their eyes throughout the procedure.
Treatment is now finished, relax the head and neck.
Brandt Daroff, home treatment (example below is to treat a right BPPV)
"This treatment requires the patient to move into the provoking position repeatedly, one or more times a day. The patient turns the head away from the side on
which he or she is going to lie down." In our example of right BPPV … "the patient turns her head 45° to the left and lies down quickly on the right side ... She
then stays in that position until the vertigo stops plus an additional 30 seconds. The patient then slowly sits up. Moving to the sitting position may also result in
vertigo, although this will be less severe and of a shorter duration. The patient should again wait until the vertigo stops before moving into the next position. The
patient then repeats the movement to the opposite side. If vertigo is provoked, the patient stays in that position until the vertigo stops and again sits up."
Herdman, S.J. (2007). Vestibular Rehabilitation - Contemporary Perspectives in Rehabilitation. (3rd ed.). Philadelphia: F.A. Davis.