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RehabMeasures Instrument

Supine Head-Hanging Positional Test

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Diagnoses Benign Paroxysmal Positional Vertigo (BPPV) of the anterior semicircular canals.

Acronym SHHPT

Area of Assessment

Balance – Vestibular



Cost Description

Test is free; Frenzel goggles cost more than $1000


  • Vestibular Disorders

Key Descriptions

  • The patient begins in long-sitting on a treatment table.
  • The patient is assisted into a supine position with the head extended off the treatment table as far as possible.
  • The clinician then observes the patient's eyes for approximately 60 seconds. A downbeating nystagmus of short duration (in absence of other central signs) is considered a positive test for anterior canal BPPV.
  • If torsion is observed, the affected ear is presumed to be the side to which the torsion is directed (ex: downward and right torsional nystagmus in the SHHPT is considered to result for right anterior canal BPPV). If there is no torsional component, this test does not assist the clinician in determining the side of involvement.
  • Benign positional paroxysmal vertigo of the anterior canal is presumed if a downward and ipsitorsional nystagmus is observed by the evaluator and the patient reports symptoms of vertigo.
  • Frenzel/Infrared goggles may be worn to assist the clinician with properly visualizing the eye(s) during the test. While it is recommended that goggles be used, the test can be performed in room light without goggles.

Number of Items


Equipment Required

  • Examination table
  • Electronystamography
  • Videonystagmography
  • Video recorder
  • Video goggles or Frenzel goggles to view nystagmus

Time to Administer

Less than 5 minutes

Required Training

Reading an Article/Manual Training Course

Age Ranges


6 - 12



13 - 17



18 - 64


Elderly Adult

65 +


Instrument Reviewers

Karen Lambert, PT, MPT, NCS and Linda B. Horn PT, DScPT, MHS, NCS of the Vestibular EDGE task force for the Neurology section of the APTA in 2013.

Body Part


ICF Domain

Body Structure

Measurement Domain

General Health


  • The parameters for this test are not defined in the literature. 

  • Cambi et al. (2013) evaluated 50 patients with positional downbeating nystagmus of peripheral origin using bilateral Dix-Hallpike (D-H) and Supine Head Hanging Tests (SHHPT):

    • In 10% of patients (5 of 50) a downbeating nystagmus was detected with the SHHPT and not with the D-H .

    • Include the SHHPT in patients with history of BPPV in which the evaluator has failed to elicit nystagmus in either D-H or Roll Test.

  • SHHPT should be administered at the beginning of vestibular battery in order to alert to the presence of multiple canal involvement.

  • Patients who are positive using the supine head hanging test tended were more likely to have multiple canal involvement, identifying that the anterior canal is affected at the beginning of the battery of vestibular tests may assist clinicians to determine if there are multiple canals affected and will allow for more accurate predictions of how long the patient's BPPV will need to be treated (Yetiser & Ince, 2014)

  • Be aware of patient history including history of trauma, use of ototoxic medications, and use of vestibular suppressants as this may affect the results of this assessment (Swan & Yorke, 2013)

Non-Specific Patient Population

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Test/Retest Reliability

Non-Specific Patient Population: (Akin & Davenport, 2003; N = 25; n = 15, patients with motion-provoked dizziness during routine daily living movements, mean age = 65 years; n = 10, patients with no complaints of motion-provoked dizziness during routine daily living movements, mean age = 66 years)

  • Excellent test-retest reliability for monitoring movement induced dizziness in patient for 90 minutes (ICC = 0.98)

  • Excellent test-retest reliability for monitoring movement induced dizziness in patient for 24 hours (ICC = 0.96)

Interrater/Intrarater Reliability

Non-Specific Patient Population: (Akin & Davenport, 2003)

  • Excellent interrater reliability for patient reports of movement induced dizziness (ICC = 0.99)

Criterion Validity (Predictive/Concurrent)

Trauma Patients: (Yetiser & Ince, 2014; N = 190 patients with BPPV symptoms; n = 12 with positional up-beating vertical nystagmus selected)

  • A positive test for BPPV using SHHP was predictive of multiple canal involvement; these patients required a significantly greater number of treatments (p < 0.05).

Construct Validity

Non-Specific Patient Population: (Akin & Davenport, 2003)

Convergent Validity

  • SHHP is very similar to other measurements commonly used to diagnose anterior canal BPPV

  • The Motion Sensitivity Test begins with the long sit to supine with head hanging movement of the SHHP

  • The Yacovino maneuver uses long sit to supine movement with head hanging movement, the client's neck is then flexed 30 degrees and eyes observed

Content Validity

Neurologic Population: (Anagnostou, Varaki, & Anastasopoulous, 2008; case study; female, aged 55; demyelinating brain lesion)

  • Downbeating nystagmus looked for during the SHHPT may occur in brainstem or cerebellar lesions.

Neurologic Population: (Imai et al., 2008)

  • Testing anterior canal BPPV using the SHHPT may be positive due to bilateral stimulation of posterior canal during the SHHPT.


Akin, F., Davenport, M., (2003). "Validity and reliability of the Motion Sensitivity Test" Journal of Rehabilitation Research & Development, 40(5): 415-422. Find it on PubMed

Anagnostou, E., Kouzi, I., & Spengos, K. (2015). Diagnosis and treatment of anterior canal benign paroxysmal positional vertigo: A systematic review. Journal of Clinical Neurology (Seoul, Korea), 11(3), 262–267. Find it on PubMed

Anagnostou E, Varaki K, & Anastasopoulos D. (2008). A minute demyelinating lesion causing acute positional vertigo. Journal of Neurological Science;266:187–189. Find it on PubMed

Califano L, Salafia F, Mazzone S, Melillo MG, Califano M. (2014). Anterior canal BPPV and apogeotropic posterior canal BPPV: Two rare forms of vertical canalolithiasis. Acta Otorhinolaryngol Ital, 34: 189–197. Find it on PubMed

Cambi, J., Astore, S., et al. (2013). "Natural course of positional down-beating nystagmus of peripheral origin." J Neurol 260(6): 1489-1496. 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.

Imai T, Takeda N, Sato G, Sekine K, Ito M, Nakamea K et al. Differential diagnosis of true and pseudo-bilateral benign positional nystagmus. Acta Otolaryngol 2008;128:151–8.

Swan, L., Yorke, A. (2013) 'An introduction to vestibular rehabilitation.' Great Lakes Seminars.

Yetiser, S., Ince, D. (2014) ‘Vertical nystagmus during the seated–supine positional (straight head-hanging) test in patients with benign paroxysmal positional vertigo’, The Journal of Laryngology & Otology, 128(8), pp. 674–678.