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Checks and Balances: A Beginner’s Guide to Vestibular Evaluation

Dr. Kelly Keener, PT, DPT

Picture this: You log onto your computer to check tomorrow’s schedule and you see that you have a vestibular evaluation. Maybe you’re unsure of what to do, because your clinic doesn’t see vestibular cases often. Or maybe you just feel somewhat intimidated by the number of different possible vestibular pathologies. Whether you’re new to the vestibular rehabilitation world or a seasoned pro- have a look through this post to review a thing or two and some helpful information.

Fast Fact

Many of us are familiar and comfortable working with the older adult population so it’s important to keep in mind:

  • Nearly 1/10 cases of BPPV get overlooked or missed because geriatric patients do not always report their symptoms1. Some patients think it is normal to experience dizziness with aging, others do not report“dizziness”, they just feel unsteady without true vertiginous episodes.

Take a Good Subjective History

For vestibular evaluations, the subjective history is one of the most important aspects of the evaluation, but also one of the most difficult. Often, patients have a hard time explaining their symptoms, so it’s important to help guide them as the clinician.

Considerations for subjective history:

  • What is the patient’s age? BPPV is most common in those 40 or older, and there are some bedside tests such as smooth pursuits where age related changes may be expected to be observed.
  • Have the patient elaborate on the term “dizziness”. Ask:
    • Do you feel faint like you’re going to pass out (syncopal)? 
    • Do you feel unsteady while walking? Can others tell you're imbalanced (dysequilibrium vs. imbalanced)
    • Do feel like you personally or your environment is“spinning” (vertigo)?
  • How long do the symptoms last? Seconds, Minutes, Hours, Days? Are they there all the time or do they come and go?
  • Are the symptoms of dizziness/vertigo ONLY positional or can they occur spontaneously, even when just sitting still?
  • What aggravates or increases your symptoms?
  • Ask about any comorbidities that may impact plan of care
    • Example: diabetes, cardiac involvement, history of stroke, head trauma, previous dizziness episodes in the past.

Perform a Bedside Evaluation: Objective Findings

This portion of the blog is more of a generalized overview tailored to those who do not have infrared or frenzel equipment available during examination. There’s a huge amount of power in your simple bedside evaluation! See our blog post “Is Bedside Testing Reliable” to discover how a simple 6-test bedside protocol is 77% sensitive for identifying vestibular disorders, as well as the site and side of the lesion.

1. Always start with a solid oculomotor examination, this will help to steer the direction of your evaluation. Some oculomotor abnormalities can be a sign of central dysfunction. So, if you start getting central findings during the oculomotor examination, keep that in mind throughout the duration of your evaluation. Also, if a patient has nystagmus at baseline it can interfere with positioning tests later in the evaluation, so it is important to know what you’re working with from the beginning.

  1. Smooth pursuit: H pattern
  2. Gaze holding
  3. Saccades: horizontal, vertical
  4. Convergence testing
  5. VOR cancellation
  6. Dynamic Visual Acuity testing (DVA)

Checkpoint: If you’re seeing nystagmus during oculomotor testing, what does it look like?

Nystagmus can get complicated, so without getting into very specific details, this is a very basic review:

  • Vestibular nystagmus has clearly defined slow and fast phase components, and it always beats to the more neurally active side. The slow phase gets generated by the peripheral vestibular system, and the fast phase is the brain stem center reset. (Ex: right beating nystagmus means that the eye slowly drifts to the L and then quickly snaps back to the R side)
  • Central nystagmus can be more complex, as there are many different presentations for nystagmus of central origin including pure torsional nystagmus, upbeating nystagmus, downbeating nystagmus, and direction changing nystagmus. So, if you are not seeing a clearly defined slow and fast phase direction fixed nystagmus, central origin should be considered.

2. Assess cervical range of motion to see if positioning tests will need to be modified.

  • You will need at least 45 degrees of cervical rotation and 30 degrees extension for Hallpike testing and 60 degrees of cervical rotation for roll testing.

3. Balance evaluation

  • Romberg, Modified Clinical Test of Sensory Interaction in Balance (mCTSIB), Sharpened Romberg
  • Gait assessment: walking with vertical and horizontal head turns, Functional Gait Assessment or Dynamic Gait Index
  • Coordination testing and sensory testing

Checkpoint: always assess lower extremity sensation, especially if all other tests are checking out to be normal. Many times, patients do not even realize they have diminished sensation in their feet, which can really impact balance and cause the unsteadiness they came to see you for.

Lastly, you’ll want to check positioning tests. Personally, I choose to assess these at the end because individuals can become very symptomatic with these tests which includes increased anxiety, nausea, and sometimes vomiting. Quick Tip: always have a trash can handy!

  • Positioning tests (recommend performing x2 cycles bilaterally to avoid false negatives with testing)
    1. Dix-Hallpike (posterior canal BPPV)
    2. Roll Test (horizontal canal BPPV)

I saw nystagmus during a positioning test, now what do I do?

Checkpoint: What does the nystagmus look like? Do the eye movements match the canal being stimulated?

  • (R or L) PSCC: upbeat, torsional (to the side being tested) nystagmus, lasting less than one minute- canalithasis
  • (R or L) PSCC: upbeat, torsional (to the side being tested) nystagmus lasting greater than one minute- cupulolithiasis
  • R HSCC: geotrophic nystagmus, lasting less than one minute, intensity greater on R- canalithiasis
  •  R HSCC: ageotrophic nystagmus lasting greater than one minute, intensity greater on L- cupulolithiasis
  • L HSCC: geotrophic nystagmus, lasting less than one minute, intensity greater on L- canalithiasis
  • L HSCC: ageotrophic nystagmus, lasting greater than one minute, intensity greater on R- cupulolithiasis

PSCC: Posterior Semi-Circular Canal
HSCC: Horizontal Semi-Circular Canal

If your positioning test shows nystagmus that matches one of the above, try performing a canalith repositioning maneuver (CRM) for the appropriate canal.

Be sure to observe the nystagmus! Just because the patient is dizzy in a Dix-Hallpike, it doesn’t necessarily mean that the Posterior Canal is the culprit. Remember Ewald’s First Law: The direction of the nystagmus is directly correlated to the canal that is being stimulated… not the position of the head. So if you see pure horizontal nystagmus in a Dix-Hallpike, you may want to perform a roll test to test for Horizontal Canal BPPV.

Choose Your Treatment

CRMs to choose from:

  1. Epley maneuver – for posterior semicircular canal canalithiasis
  2. Semont maneuver- for posterior semicircular canal cupulolithiasis
  3. Gufoni maneuver or BBQ Roll- can be used for both cupulolithiasis and canalithiasis variants of BPPV

Bonus checkpoint: Now, how should this be documented?

All other objective findings can be documented accordingly, however positive positioning tests may require a little extra clarification. It’s important to name the eye movements and characteristics thereof to ensure others reading your document will know exactly what was observed upon evaluation.

Ex: (for right, posterior semicircular canal BPPV): R Dix Hallpike (x2 cycles): R torsional, upbeat nystagmus, x7 seconds, with subjective report of vertigo, latency of nystagmus appreciated.

Ex: (for treatment of right, posterior semicircular canal BPPV): CRM performed for R posterior canal (x1 cycle), no reversal of nystagmus noted with return to sit following treatment.

In conclusion, this is a very basic guide. Every patient is different and there are times that additional tests or measures will need to be performed. However, this a good general outline to help simplify or organize your vestibular evaluation.

If you have any questions about specific tests or techniques or would like to have a discussion regarding a vestibular case feel free to comment below, or email any questions to

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Kelly Keener, PT, DPT

Certificate in Vestibular Rehabilitation, 2019


  1. Oghalai J, Manolidis S, Barth, J, et al. Unrecognized Benign Paroxysmal Positional Vertigo in Elderly Patients. Otolaryngol. Head Neck Surg. May 1, 2000. Vol 122 Issue 5. Page 630-634.
  2. Herdman S, Clendaniel R. Vestibular Rehabilitation Fourth Edition. 2014. ©F.A. Davis Company