Dix–Hallpike Maneuver

Last Updated

June 20, 2013

Purpose

The Dix-Hallpike Maneuver diagnoses Benign Paroxysmal Positional Vertigo (BPPV) of the Posterior Semicircular Canal.

Acronym Dix–Hallpike

Area of Assessment

Vestibular

Assessment Type

Observer

Cost

Free

Diagnosis/Conditions

Brain Injury
Vestibular Disorders

Movement and Gait Disorders

The patient begins in long-sitting on a treatment table. Frenzel/Infrared goggles may be worn to assist the clinician to properly visualize the eye(s) during the test procedure. While it is recommended that goggles be used, the test can be performed in room light without goggles.
Procedures:
1) The patient is instructed to rotate his/her head 45 degrees toward the direction of the ear being tested.
2) With the assistance of the clinician, the patient is then instructed to quickly lie back onto the table so that their neck is extended approximately 30 degrees.
3) If the patient lacks cervical extension, the test position can be modified by positioning a pillow or wedge under the patient's shoulders.
4) The clinician then observes the patient's eyes for approximately 60 seconds.
Benign positional paroxysmal vertigo of the posterior canal is diagnosed if an upward and ipsitorsional nystagmus is observed by the evaluator and the patient reports symptoms of vertigo.
If the Dix-Hallpike maneuver cannot be easily administered due to cervical range of motion limitations, the side-lying test may yield similar results (see Cohen, 2004, for more information).

Examination table
Frenzel Goggles (recommended, cost > $1000)

Less than 5 minutes

Required Training

Reading an Article/Manual

Child

6 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jason Raad, MS in 4/2012.Reviewed and Updated by Karen Lambert PT, MPT, NCS and Linda B. Horn PT, DScPT, MHS, NCS of the VEDGE task force for the Neurology section of the APTA in 2013

Body Part

Head

ICF Domain

Body Structure

Measurement Domain

Sensory

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

*Abbreviations:*
HR	Highly Recommend
R	Recommend
*LS / UR*	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations for use based on acuity level of the patient:

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 weeks)

Vestibular EDGE

Recommendations based on vestibular diagnosis

	Peripheral	Central	Benign Paroxysmal Positional Vertigo (BPPV)	Other
Vestibular EDGE	LS	LS	HR	LS

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
Vestibular EDGE	Yes	Yes	Yes	Yes

Considerations

Due to the frequency of BPPV that has been detected in individuals who had not previously reported symptoms, the VEDGE task force recommends performing positional testing to rule out positional vertigo when assessing any patient that complaints of dizziness and balance impairments
Some training is recommended (through coursework or article review) to assist with technique and interpretation (as improper positioning could result in a false negative test)
If a patient is unable to attain proper positioning for the Dix-Halpike test, an alternative test (such as the sidelying test) should be performed
11% of patients may have false-negative results when first assessed (Burston et al, 2012)
Up to 25% of patients with BPPV may not demonstrate nystagmus during the Dix–Hallpike test (Noda et al, 2011)

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Normative Data

Rates of Benign Paroxysmal Positional Vertigo (BPPV) in young population:

(Kerrigan et al. 2012; n = 198; 99 male, 99 female, aged 18-34, healthy subjects without complaints of dizziness or imbalance)

9% (12% female, 5% male) with positionally induced nystagmus

Rates of Benign Paroxysmal Positional Vertigo (BPPV) in elderly population:

(Ogahali et al. 2000; n = 100; 28 male, 72 female, aged 51-95, patients treated in a geriatric clinic without previous reported

9% with positive dix-hallpike testing

Lifetime prevalence:

(von Brevern et al. 2003; n = 1003)

Lifetime prevalence 2.4% (3.2% female, 1.6% male)
Mean age of onset 49.4 years (SD 13.8)

(Liu 2012; n = 86)

16% patients with dizziness = bppv katsarkas

Interrater/Intrarater Reliability

Adults with a history of vertigo

(Burston et al, 2012)

Excellent agreement between two assessors (Kappa = 0.92; 95% CI: 0.87–0.98)

Criterion Validity (Predictive/Concurrent)

Predictive Validity

Benign Paroxysmal Positional Vertigo:

(Pollak et al, 2002; n = 58 patients with BPPV who were treated during the past 4 years; mean age = 55.8(14.2) years)

78% of patients (18 of 23) with positive Dix-Hallpike as only sign of vestibular dysfunction in laboratory testing did not demonstrate positional nystagmus after one particle repositioning maneuver
74% of patients (43 of 58 total patients in study) with positive Dix-Hallpike did not demonstrate positional nystagmus after one particle repositioning maneuver
38% (22 of 58 total patients) remained symptomatic despite negative Dix-Hallpike follow-up tests.

Responsiveness

Responsiveness:

(Pollak et al, 2002; n = 58 patients with BPPV who were treated during the past 4 years; mean age = 55.8(14.2) years)

74% of patients (43 of 58 total patients in study) with positive Dix-Hallpike did not demonstrate positional nystagmus after one particle repositioning maneuver
38% (22 of 58 total patients) remained symptomatic despite negative Dix-Hallpike follow-up tests.

Bibliography

Burston, A., Mossman, S., et al. (2012). "Are there diurnal variations in the results of the Dix-Hallpike manoeuvre?" J Clin Neurosci 19(3): 415-417. Find it on PubMed

Cohen, H. S. (2004). "Side-lying as an alternative to the Dix-Hallpike test of the posterior canal." Otol Neurotol 25(2): 130-134. Find it on PubMed

Dix, M. and Hallpike, C. (1952). "The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system." Proceedings of the Royal Society of Medicine 45(6): 341.

Gordon, C. R., Levite, R., et al. (2004). "Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form?" Arch Neurol 61(10): 1590. Find it on PubMed

Halker, R. B., Barrs, D. M., et al. (2008). "Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic." Neurologist 14(3): 201-204. Find it on PubMed

Kerrigan, M. A., Costigan, M. F., et al. (2013). "Prevalence of benign paroxysmal positional vertigo in the young adult population." PM R 5(9): 778-785. Find it on PubMed

Noda, K., Ikusaka, M., et al. (2011). "Predictors for benign paroxysmal positional vertigo with positive Dix-Hallpike test." Int J Gen Med 4: 809-814. Find it on PubMed

Oghalai, J. S., Manolidis, S., et al. (2000). "Unrecognized benign paroxysmal positional vertigo in elderly patients." Otolaryngology - Head and Neck Surgery 122(5): 630-634. Find it on PubMed

Pollak, L., Davies, R. A., et al. (2002). "Effectiveness of the particle repositioning maneuver in benign paroxysmal positional vertigo with and without additional vestibular pathology." Otology & neurotology 23(1): 79. Find it on PubMed

Last Updated

Purpose

Area of Assessment

Assessment Type

Cost

Diagnosis/Conditions

Required Training

Instrument Reviewers

Body Part

ICF Domain

Measurement Domain

Professional Association Recommendation

Considerations

Normative Data

Interrater/Intrarater Reliability

Criterion Validity (Predictive/Concurrent)

Responsiveness

Bibliography

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