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The loaded Dix-Hallpike test for BPPV

Does a slight change to the Dix-Hallpike maneuver yield better test results?

Benign paroxysmal positional vertigo (BPPV) is a common form of dizziness. The physiology of BPPV is when otoconia (often referred to as ‘crystals’ or free floating particles in the semicircular canal) influence the vestibular neurological signal to the brain when the head moves. The Dix-Hallpike test is a common test for assessing the posterior canal to see if BPPV is present.

Previous studies have suggested that a poor testing result may be due to the positioning of the otoconia in the canal prior to the full testing procedure. The authors of this article investigated whether a ‘loaded’ head positioning prior to testing would produce a greater duration and/ or more intense nystagmus response so that the assessor can establish a positive test easier.

It was found that the L-DH produced a longer nystagmus; as a result it may be easier for clinicians to detect.

As an important limit of this study, the authors do mention that only participants who were able to tolerate repetitive testing were included.

Moreover, given the fact that the L-DH increased the intensity of nystagmus and reported symptoms, clinicians should consider whether or not the patient is able to tolerate the L-DH positioning in the future.

> From: Andera et al., J Int Adv Otol 16 (2020) 171-175 . All rights reserved to The Author(s). Click here for the online summary.

Want to read deeper into this topic? A free version of the full text can be found online here!

Expert opinion

This study discusses an alternative to the Dix-Hallpike, which can be helpful in ascertaining a diagnosis of BPPV.

One limitation not noted in this study was the possibility of fatigue of symptoms with L-DH versus the S-DH. It is often stated that repetitive testing of the Dix-Hallpike maneuver may cause a reduction in symptoms and nystagmus in some patients due to fatigue of positional response if tested several times close together.

While this was not addressed in this paper, it should be a consideration for future clinical application when doing a S-DH or a L-DH. For those able to tolerate a potentially more intense testing position, perhaps just one test of the L-DH may be better tolerated and yield a better result.

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