Primary Image

Head Shaking

Head Shaking Nystagmus Test

Last Updated

Purpose

The purpose of the HSN test is to identify peripheral vestibular dysfunction. Rapid head shaking and abrupt stopping may elicit nystagmus in patients with vestibular imbalance.

Acronym HSN

Area of Assessment

Vestibular

Assessment Type

Performance Measure

Cost

Free

Diagnosis/Conditions

  • Pediatric & Adolescent Rehabilitation
  • Vestibular Disorders

Key Descriptions

  • It is recommended that the clinician tilts the patient’s head ~ 30 degrees downward, and then oscillates the patient’s head horizontally (passively) 20-30 cycles at 1-2 Hz.
  • The patient is instructed to keep eyes open, or should open his/her eyes before the end of 30 cycles if they had been closed.
  • Elicitation of 3 or more beats of nystagmus suggests a vestibular imbalance with quick phase eye movements beating toward the more neurologically active side.
  • Patient may wear Frenzel lenses (Frenzel’s glasses) or infrared lenses.
  • Electronystagmography (ENG) or videonystagmography (VNG) equipment may be utilized to perform HSN assessment assuming appropriate access and training.

Number of Items

1

Equipment Required

  • Preferred equipment: Infrared lenses
  • Suggested equipment: Frenzel lenses
  • Equipment used in research: Videonystamography (VNG) / Electronystagmography

Time to Administer

Less than 2 minutes

Required Training

Training Course

Age Ranges

Children

6 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jennifer Stoskus, PT, MSPT, DPT; Matthew Scherer PT, PhD, NCS and the Vestibular EDGE task force of the Neurology section of the APTA.

Body Part

Head
Neck

ICF Domain

Body Structure
Body Function

Measurement Domain

Motor
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 months)

(Vestibular > 6 weeks post)

Vestibular EDGE

LS

 

LS

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

Vestibular EDGE

LS

LS

NR

NR

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

No

Yes

No

Yes

Considerations

  • Patient should be cleared of vascular and orthopedic contraindications (i.e. vertebral artery integrity and cervical stability) and demonstrate full, pain-free active range of motion in the plane of testing.

  • The HSN test provides information regarding peripheral vestibular system imbalance

  • Sensitivity of the HSN test improves as vestibular imbalance increases between R/L sides (as indicated with caloric testing)

  • Many studies of HSN use ENG equipment or a scleral search coil, which is not utilized in most clinical settings; few studies look at psychometrics using infrared lenses or Frenzel glasses, however this equipment is most commonly used in current clinical practice.

  • Methods used in older studies included the patient actively shaking his/her head, while common current practice, it is recommended that the clinician perform a passive head shake in order to ensure appropriate head position, velocity of headshaking, and stillness of the head after headshaking.

  • Overall recommendation: The HSN test is a brief test that can be added to a clinicians testing battery, however should not be used as a stand alone test; there is higher likelihood of vestibular dysfunction when both the HSN test and Head Impulse Test are both abnormal.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Vestibular Disorders

back to Populations

Criterion Validity (Predictive/Concurrent)

Predictive Validity

Vestibular Tone Imbalance:

Study

= number studied

Mean Age (years)

Sensitivity

Specificity

Asawavichiangianda et al, 1997

300 

Organic Vestibular including central = 198 

Non-organic = 57 

Psychogenic = 57 

Unknown = 45 

Total mean age = 48.4 

31.7% 

Not reported 

Asawavichiangianda et al, 1999

1364 

Control = 50 

 

50.2% in pts with > 20% difference in canal excitability 

73.2% in pts with > 20% difference in canal excitability 

Burgio et al, 1991

115: 

UVL = 25 

BVL = 10 

Dizziness with normal ENG = 80 

Control =17 

Not reported 

UVL = 44% 

BVL = 40% 

Dizziness with normal ENG = 50% 

Not reported 

Fujimoto et al, 1993

1364 

48.2 

50.21% in pts with > 20% difference in canal excitability 

73.18% in pts with > 20% difference in canal excitability 

Goebel and Garcia, 1992

214 

55 

42% 

Positive Predictive Value = 44% 

85% 

Negative Predictive Value = 84% 

Hain et al, 1987

13: 6 s/p acoustic neuroma resection, 7 controls 

Not reported 

100% 

0% 

Harvey et al, 1997

105 

52.1 

35% 

Positive Predictive Value = 50% 

92% 

Negative Predictive Value = 86% 

Jacobson et al, 1990

116 

Not reported 

27% 

85% 

Kamei, 1988

       

Takahashi et al, 1990

85 

44 ±10.2 

83% 

Not reported- 29%? 

Tseng and Chao, 1997

258 

14-79 

90% 

53% 

Vincini et al, 1989

277 

47.3 

44% in peripheral dysfunction 

22.5% central vestibular dysfunction 

Not reported 

Wei et al, 1989

108 

49 ±18 

32% 

Positive Predictive Value = 32% 

60% 

Negative Predictive Value = 75% 

Tseng (1997) reported the head-shaking nystagmus test a sensitive measure to predict vestibular tone imbalance with canal paresis set to at least 20%. 

 

Vestibular Dysfunction:

Asawavichianda et al. (1997) reported a higher incidence of HSN in patients with peripheral dysfunction. Also that caloric testing and HSN correlated well with peripheral dysfunction than other tests on ENG, and there is a greater chance of HSN or strong HSN if there is vestibular nerve involvement. 

Sensitivity of Head Shaking Nystagmus in Patients with Peripheral Vestibular Dysfunction

 

 

 

 

Diagnosis

n = number studied

HSN (+)

Sensitivity

Meniere’s

31

18

58.1

Acoustic neuroma

21

10

47.6

Vestibular neuronitis

8

4

50.0

Recurrent vestibulopathy

26

9

30.8

BPPV

63

18

28.6

Other

16

5

31.4

Unknown

27

12

44.4

 

Incidence of HSN in patients/controls with vestibular asymmetry of 20% or less = 56% Hall et al, 1991: (n = 360, 340 with vestibular asymmetry and 20 controls; mean age = not reported): 

  • Incidence of HSN in patients with > 50% vestibular asymmetry = 73% 

 

Criterion validity: 

Harvey et al. (1997) found that when both the Head Impulse Test and Head Shaking Nystagmus Test are abnormal, there is a high likelihood of caloric deficit. 

  • Sensitivity when both tests were abnormal = 20% 
  • Specificity when both tests were abnormal = 88%

Construct Validity

Convergent Validity: 

Peripheral Vestibular Dysfunction

Fujimoto et al., 1993 (= 1364; mean age = 48.2): Peripheral vestibular dysfunction 

  • High correlation between HSN and spontaneous nystagmus, positional nystagmus, and caloric test abnormalities, but not correlated with oculomotor abnormalities. Likelihood increases with greater difference in caloric test excitability (Table 1, Table 2) 
  • Correlation with positional nystagmus:
    • Chi score = 49.28 
    • Sensitivity = 57.3% 
    • Specificity = 71.2% 

 

Table 1: Fujimoto et al, 1993 

Correlation between ENG findings and HSN

Sensitivity

Specificity

Spontaneous nystagmus

55.8% 

71.5% 

Oculomotor exam (abnormal)

35.6% 

68.7% 

Positional nystagmus

57.3% 

71.2% 

Caloric reduction

50.2% 

73.2% 

 

Table 2: Fujimoto et al, 1993 

R/L excitability

> 20% 

> 40% 

> 60% 

> 80% 

Sensitivity

50.21 

64.36 

68.33 

77.14 

Specificity

73.18 

71.69 

70.68 

70.14

Bibliography

Asawavichiangianda, S., Fujimoto, M., et al. (1999). "Significance of head-shaking nystagmus in the evaluation of the dizzy patient." Acta Otolaryngol Suppl 540(540): 27-33. Find it on PubMed

Asawavichianginda, S., Fujimoto, M., et al. (1997). "Prevalence of head-shaking nystagmus in patients according to their diagnostic classification in a dizziness unit." The Journal of otolaryngology 26(1): 20-25.

Burgio, D. L., Blakley, B. W., et al. (1991). "An evaluation of the head-shaking nystagmus test." Otolaryngol Head Neck Surg 105(5): 708-713. Find it on PubMed

Fujimoto, M., Rutka, J., et al. (1993). "A study into the phenomenon of head-shaking nystagmus: its presence in a dizzy population." The Journal of otolaryngology 22(5): 376-379.

Goebel, J. A. and Garcia, P. (1992). "Prevalence of post-headshake nystagmus in patients with caloric deficits and vertigo." Otolaryngol Head Neck Surg 106(2): 121-127. Find it on PubMed

Hain, T. C. and Spindler, J. (1993). "Head-shaking nystagmus." The vestibulo-ocular reflex and vertigo. New York: Raven: 217-217.

Hall, S. and Laird, M. (1992). "Is head-shaking nystagmus a sign of vestibular dysfunction?" The Journal of otolaryngology 21(3): 209.

Harvey, S. A., Wood, D. J., et al. (1997). "Relationship of the head impulse test and head-shake nystagmus in reference to caloric testing." Am J Otol 18(2): 207-213. Find it on PubMed

Jacobson, G. P., Newman, C. W., et al. (1990). "Sensitivity and specificity of the head-shaking test for detecting vestibular system abnormalities." Ann Otol Rhinol Laryngol 99(7 Pt 1): 539-542. Find it on PubMed

Kamei, T. (1988). "Two types of head-shaking tests in vestibular examination." Acta Otolaryngol Suppl 458(S458): 108-112. Find it on PubMed

Takahashi, S., Fetter, M., et al. (1990). "The clinical significance of head-shaking nystagmus in the dizzy patient." Acta Otolaryngol 109(1-2): 8-14. Find it on PubMed

Tseng, H. Z. and Chao, W. Y. (1997). "Head-shaking nystagmus: a sensitive indicator of vestibular dysfunction." Clin Otolaryngol Allied Sci 22(6): 549-552. Find it on PubMed

Vicini, C., Casani, A., et al. (1989). "Assessment of head shaking test in neuro-otological practice." ORL J Otorhinolaryngol Relat Spec 51(1): 8-13. Find it on PubMed

Wei, D., Hain, T. C., et al. (1989). "Head-shaking nystagmus: associations with canal paresis and hearing loss." Acta Otolaryngol 108(5-6): 362-367. Find it on PubMed

Save now, read later.