Demystifying the Vestibular Exam

The vestibular system, one of the more mysterious realms of physical therapy, can be described as a delicate balance of opposites. It relies on some of the body's smallest structures, the intricate components of the inner ear, while also engaging its largest organ-the skin. To complete the recipe, vision adds the final garnishing that blends these elements into a seamless system that functions subconsciously. Keeping upright and oriented may be an aspect of life that most people take for granted, but our patients with vestibular dysfunctions quickly learn how important it is to have this system working properly. Between the endless list of conditions and variations in patient presentations, the world of neurological physical therapy contains some of the most complex topics to understand for students and new practitioners. The vestibular system is no stranger to this complexity, but we like to bring it back to the basics. In this newsletter edition our goal is to demystify the vestibular exam process and practically integrate it into your unique practice.

Simplifying Your Approach to Tackling “Dizziness”?

As with any patient examination that we do, establishing a strong subjective history will give you good evidence to direct your practical tests and feed your clinical reasoning. We recommend that you ask open-ended questions that allow for the patient to disclose what they are feeling in their own words before asking more leading questions to parcel out specific information. Below I have listed some of the common symptoms that patients may disclose hinting towards the vestibular system.

Subjective Symptoms: ‘Dizziness’ (Vertigo, lightheadedness or imbalance?), light sensitivity, visual changes, nausea, auditory changes, flu-like features, tripping/falling, trouble walking, difficulty with positional transitions, neck stiffness. 

A characteristic report from patients is that they have feelings of dizziness, but this is too vague for us to proceed. We need to pull further on this thread to find out if it is true vertigo, lightheadedness or a general feeling of instability. True vertigo (feelings of oneself, the room, or both spinning) is a stronger indication of a vestibular disorder whereas lightheadedness and instability can be explained by various cardiovascular, neurological or endocrine conditions that need further differential diagnosing¹. 

As we are digging into the information that the patient is presenting us, we cannot forget to ask ourselves a key question that will guide their vestibular rehabilitation. Central or peripheral? When trying to differentiate between these two I like to try to relate the symptoms to a boxing match or a marathon. Like going 10 rounds in the ring with a professional boxer, peripheral symptoms hit hard and they hit fast. Their vertigo onset is sudden, while being brief or episodic the symptoms are severe, nausea is more frequent and hearing changes can occur. On the other hand, central symptoms are like a marathon sounding drawn out and exhausting. The onset of vertigo is typically slow and possibly insidious reaching varying levels of intensity. When symptoms arise they tend to stick around for a while and other central nervous system signs are present (think mentation changes, inappropriate sympathetic responses, etc.).

Here’s a realistic complication, you still don’t know what is going on for sure. You think you can confidently say that there is a vestibular problem going on but there was too vague of a description to narrow down whether it is central or peripheral. Not to worry! This is why we verify our hypotheses with objective measures. We recommend evaluating all neurological patients with a fundamental approach that screens for deficits in mental status, cranial nerve function, vision screening, sensation, balance, and coordination. Especially for new practitioners, incorporating these elements into your exam will allow you to rule in/out differential causes to patient symptoms. Below I have included a list of specific vestibular exam components and their central or peripheral presentations.

Vestibular Practical Testing:

When looking at this chart it is easy to get overwhelmed with the number of tests that can be done to differentiate between a central and peripheral vestibular disorder. To keep it simple I divert to pattern recognition. Peripheral disorders tend to show dysfunction when the patient’s head is moving which is consistent with the structures that are affected. Conversely, central disorders there is a faulty signaling process that does not require head movement to show symptoms. 

The BPPV of It All

At this point you have completed quite a thorough vestibular examination, to which we commend you. Bravissimo/a! Overall it is estimated that up to 80% of all vestibular dysfunction is caused by peripheral system pathology so it is very likely that you will be proceeding to ask yourself if BPPV is present. What is that? The single most common peripheral vestibular condition, Benign Paroxysmal Positional Vertigo (BPPV)³. Between involvement of each set of semicircular canals and their ampullae there are a total of 12 separate BPPV diagnoses that are possible. Most cases will tend to be a posterior canalithiasis but we must test to verify this rather than assuming.

To gather knowledge we must enlist help from the Dix-Hallpike and Barbecue Roll maneuvers¹. Each of these were created to allow practitioners to make consistent and accurate diagnoses answering our two key questions. To begin we always recommend that you test the side you expect to be unaffected before the side you suspect to elicit symptoms. This is for the patient’s sake and to promote an efficient flow into treatment. Below I have included a flowchart that outlines key results that will lead you to an accurate differential diagnosis.

Clinical Considerations

Your favorite restaurant, the car dealership, the grocery store, what do they all have in common? The customer is always right. While it might take some tweaking, we can apply this statement to our practice in the sense of knowing what is appropriate to do with the patient in front of you. Listening to a medical history, reading a chart and recognizing comorbidities all need to be a focal part when choosing what tests we can do. The Dix-Hallpike and Barbecue Roll tests put patients in positions that are stressful for many orthopedic and cardiovascular conditions. Being in the moment and genuinely asking yourself what could go wrong before completing these tests is always best practice. Alternatives to the Dix-Hallpike maneuver include the Side Lying Dix-Hallpike and Semont test that consider cervical extension limitations¹. For the Barbecue Roll test, the upright head roll variation as well as the Bow and Lean test avoid putting the patient in supine and prone positions for patients that cannot tolerate this^4,2.

Parting Words

Like crafting a perfect dish, a thorough vestibular examination requires the right ingredients, careful preparation, and a keen understanding of the flavors at play. A patient’s symptoms, the menu, offering clues about what might be causing their ‘dizziness’. The subjective interview, the appetizer, setting the stage for the main course by identifying key triggers, symptom duration, and associated factors. The neurological and vestibular tests serve as the chef’s toolkit—each assessment, from smooth pursuits to the Dix-Hallpike, is a specialized knife or pan, helping to differentially diagnose with precision. All of it comes together in a whirlwind fueled by keen clinical reasoning to guide our patient forward through their rehabilitation.

Case Study Example

Jane Doe, a 58-year-old female, reports experiencing sudden episodes of dizziness over the past two weeks. She describes the sensation as a brief spinning of the room, rather than lightheadedness or faintness. The episodes typically last 15 to 30 seconds and occur when she rolls over in bed or tilts her head back, such as when reaching for an item on a high shelf.

Jane notes that the dizziness is sometimes accompanied by moderate to severe nausea, but she denies headaches, double vision, speech difficulties, or weakness. She has not experienced any hearing loss, ringing in her ears, or a sensation of fullness in the ears. Although she feels mildly unsteady immediately after an episode, she has not fallen.

She reports no history of recent illness, fever, or ear infections, and there have been no significant changes in her health otherwise. The symptoms have been disruptive, particularly when trying to sleep, but they resolve on their own within seconds.

To rule out central causes (e.g., stroke, multiple sclerosis), the PT performs:

• Mental Status: Alert, oriented to person, place, and time.

• Cranial Nerve Function: No deficits in CN II-XII.

• Vision Screening: No diplopia, normal visual fields.

• Sensation: Intact light touch and proprioception in upper and lower extremities.

• Balance Assessment: Mild unsteadiness on tandem stance, negative Romberg test.

• Coordination: Normal finger-to-nose and heel-to-shin tests.

Dix-Hallpike Test:

• Right Side: Positive for vertigo and torsional upbeating nystagmus, lasting approximately 20 seconds.

• Left Side: Negative, no symptoms or nystagmus observed.

PT Diagnosis:

• Benign Paroxysmal Positional Vertigo (BPPV) – Right Posterior Canal

• Findings suggest canalithiasis of the right posterior semicircular canal, given the positional nature of symptoms, positive right Dix-Hallpike test, and abnormal right-sided vestibular function on VOR and Head Thrust testing.

References:

1. Fell D, Lunnen K, Rauk R. Lifespan Neurorehabilitation. F.A. Davis Company; 2018.

2. The Bow and Lean Test. The Bow and Lean Test. Accessed February 9, 2025. https://www.vestibular.today/blog/the-bow-and-lean-test

3. Hung SH, Xirasagar S, Dang LH, et al. Trends in the incidence of peripheral vestibular disorders: a Nationwide population-based study. Front Neurol. 2023;14. doi:10.3389/fneur.2023.1322199

4. Malara P, Castellucci A, Martellucci S. Upright head roll test: A new contribution for the diagnosis of lateral semicircular canal benign paroxysmal positional vertigo. Audiol Res. 2020;10(1):236. doi:10.4081/audiores.2020.236

Disclaimer:

We are current Doctor of Physical Therapy (DPT) students sharing information based on our formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While we strive to provide accurate and up-to-date information, our knowledge is based on our current academic and clinical rotations and ongoing learning, not extensive clinical practice.