How to perform the Dix-Hallpike, roll, head impulse and other bedside vestibular tests, what a positive means, the cautions, and what the research says about accuracy.
For clinician education; bedside vestibular tests support, but do not replace, a full examination and medical diagnosis. This page is a reference for physical therapists, occupational therapists, students and other clinicians trained in vestibular assessment. Positional tests provoke vertigo and nausea, and some tests involve fast neck movement; perform them only if you are trained and have screened for the cautions listed.
Bedside tests for BPPV, vestibular hypofunction and cervicogenic dizziness: how to perform each one, what a positive finding means, the cautions that go with it, and accuracy figures only where we could check the source.
Spinning when you roll over in bed or look up, blurry vision when you move your head, or feeling off balance are common and often treatable. The most common cause of positional vertigo, BPPV, usually responds to a few simple repositioning maneuvers, and vestibular rehabilitation helps many people with inner-ear balance problems.[3] These tests should be done by a trained clinician, not at home. Read our plain-language guide to vertigo and BPPV, and to be evaluated by a Holsman physical therapist who treats vertigo and balance problems, request an appointment or call 1-855-465-7626. If your dizziness came on suddenly with any of the warning signs below, call 911 instead.
🚨 Red flags: send to emergency care (call 911)
Dizziness or vertigo with any of these needs emergency medical evaluation, not a therapy visit:
Sudden weakness, numbness or drooping of the face, arm or leg, especially on one side
Slurred speech, trouble speaking or understanding (dysarthria or aphasia), or trouble swallowing
Double vision or sudden loss of vision
A new, severe or “worst ever” headache, or new neck pain after trauma or manipulation
Inability to stand or walk unaided, new clumsiness or loss of coordination
New, continuous vertigo with nystagmus lasting hours (acute vestibular syndrome), or nystagmus that is purely vertical, changes direction with gaze, or does not fit BPPV
Fainting, chest pain, palpitations or shortness of breath
Sudden hearing loss with vertigo
Bedside tests in a therapy clinic cannot rule out a stroke. Physical therapists do not diagnose stroke; when central signs appear, stop testing and arrange urgent medical care.
Before you test
Take a careful history first. Timing and triggers (brief and positional, spontaneous episodes, or continuous) guide which tests make sense. The 2017 BPPV guideline asks clinicians to tell BPPV apart from other causes of dizziness and to check for factors such as impaired balance, central nervous system disease and fall risk.[2]
Use goggles when you can. Frenzel or video goggles remove visual fixation, which can hide peripheral nystagmus.
Screen the neck and circulation. Several tests need brisk or sustained neck movement. Check for neck injury, instability and vascular risk, and choose the side-lying or whole-body versions when needed.
Context from the profession. The Academy of Neurologic Physical Therapy’s Vestibular EDGE task force reviewed many of these bedside measures, including the Dix-Hallpike, roll, bow and lean, head impulse, head-shaking nystagmus, non-instrumented dynamic visual acuity and bucket tests; see neuropt.org for their recommendations.[1] The 2022 APTA vestibular rehabilitation guideline (Hall et al.) recommends offering vestibular rehabilitation to adults with peripheral vestibular hypofunction.[3]
Sn = sensitivity, Sp = specificity, LR = likelihood ratio. A dash means the source we checked did not report that value.
How to read the accuracy numbers
Sensitivity: of people who have the condition, the share with a positive test. A highly sensitive test that is negative helps rule the condition out.
Specificity: of people without the condition, the share with a negative test. A highly specific test that is positive helps rule it in.
Positive likelihood ratio (+LR): how much a positive result raises the odds. About 5–10 is a moderate shift; above 10 is large.
Negative likelihood ratio (−LR): how much a negative result lowers the odds. About 0.1–0.2 is a moderate-to-large shift; near 1 means little change.
Values depend on the study’s patients, examiners and reference standard. Many studies are small, so treat single-study numbers with caution.
Vestibular and BPPV tests, step by step
Each test is described in our own words. Explain each step, keep the patient safe from falls, and stop if severe symptoms or any red flag appears.
Dix-Hallpike test
Also called: Dix-Hallpike maneuver; Hallpike-Dix
Purpose
Provokes the typical nystagmus of posterior canal BPPV, the most common form of BPPV.
Patient position
Long sitting on a plinth, positioned so the head can hang just past the end of the table when lying down. Remove glasses; Frenzel or video goggles help if available.
Explain that brief, intense spinning and nausea may occur and usually pass within a minute.
Turn the head about 45° toward the side being tested and hold it there with both hands.[2]
Lower the patient briskly to lying, with the neck extended about 20° below horizontal and the head still turned.[2]
Watch the eyes for at least 30 seconds, then longer if nystagmus appears, until it settles.
Bring the patient back to sitting slowly, watch again, then repeat to the other side.
Positive finding
Vertigo with upbeating, torsional nystagmus (upper pole of the eye beating toward the lower ear) after a short delay, building and then fading within about 60 seconds, points to posterior canal BPPV on the lower side. Horizontal or no nystagmus in a patient with a typical history calls for the supine roll test.[2]
Cautions
The 2017 guideline reports no documented cases of vertebrobasilar insufficiency caused by the maneuver, but advises care in significant vascular disease and in cervical stenosis, severe kyphoscoliosis, limited neck motion, Down syndrome, severe rheumatoid arthritis, cervical radiculopathy, Paget’s disease, ankylosing spondylitis, low back problems, spinal cord injury and severe obesity.[2] Use the side-lying test or a tilting table instead when positioning is unsafe. Screen first for neck pain, recent neck trauma, cervical instability and vascular risk; stop and refer if the patient develops double vision, slurred speech, trouble swallowing, facial numbness, limb weakness or numbness, or loss of coordination.
Evidence notes
Delay usually 5–20 seconds, rarely up to a minute; the response tends to fatigue when repeated.[2] Nystagmus that starts with no delay, lasts beyond a minute, does not fatigue, or beats purely down or in another atypical direction is not typical of BPPV and needs medical review.
Turn the head about 45° away from the side being tested.[5]
Lie the patient down briskly onto the tested side, keeping the head turned so the face points slightly up.
Watch the eyes until any nystagmus settles, sit the patient up, then test the other side.
Positive finding
The same upbeating, torsional nystagmus as a positive Dix-Hallpike test, toward the lower ear.
Cautions
Avoids neck extension, but still needs a brisk move and neck rotation. Screen first for neck pain, recent neck trauma, cervical instability and vascular risk; stop and refer if the patient develops double vision, slurred speech, trouble swallowing, facial numbness, limb weakness or numbness, or loss of coordination.
Evidence notes
In 61 patients tested both ways, side-lying and Dix-Hallpike results did not differ significantly.[5]
Turn the head quickly about 90° to one side and watch for horizontal nystagmus.[2]
When it settles, return the head to face up and wait.
Turn the head quickly about 90° to the other side and watch again.[2]
Positive finding
Geotropic: horizontal nystagmus beating toward the floor on each side; the side with the stronger nystagmus is usually the affected ear. Apogeotropic: nystagmus beating toward the ceiling on each side; the affected ear is usually opposite the stronger side.[2]
Cautions
Turning the head on the trunk needs neck rotation; a patient who cannot turn the head can roll the whole body instead. Screen first for neck pain, recent neck trauma, cervical instability and vascular risk; stop and refer if the patient develops double vision, slurred speech, trouble swallowing, facial numbness, limb weakness or numbness, or loss of coordination.
Evidence notes
The 2017 guideline recommends a supine roll test when the history fits BPPV and the Dix-Hallpike test shows horizontal or no nystagmus. Horizontal canal BPPV made up about 5–22% of BPPV in referred groups, and the affected side stays unclear in about 20% of cases.[2]
Diagnostic accuracy
Accuracy data not verified. We did not find a sensitivity and specificity study for this bedside test that we could check, so we show no numbers here.
▶Video demonstration coming soonFilmed by Holsman physical therapists
Bow and lean test
Also called: Choung test
Purpose
Helps identify the affected ear in horizontal canal BPPV when the roll test is unclear.
Bend the head forward (bow) and watch for horizontal nystagmus.
Return to upright, then tilt the head backward (lean) and watch again.
Note the direction of each nystagmus.
Positive finding
In the canalolithiasis (geotropic) form, the affected ear is on the side toward which the bowing nystagmus beats; in the cupulolithiasis (apogeotropic) form, the side toward which the leaning nystagmus beats.[6]
Cautions
Some patients show no bowing or leaning nystagmus. Neck flexion and extension may be uncomfortable; respect neck precautions.
Evidence notes
In 26 patients, the bow and lean test pointed to a different ear from the classic roll-test method in 7 (26.9%).[6] In a later study of 225 cases, remission after two repositioning sessions was 83.1% when bow and lean findings guided treatment vs 67.4% with the roll test alone, in the canalolithiasis type (P = .041).[7]
Diagnostic accuracy
Accuracy data not verified. We did not find a sensitivity and specificity study for this bedside test that we could check, so we show no numbers here.
▶Video demonstration coming soonFilmed by Holsman physical therapists
Head impulse test (bedside)
Also called: Head thrust test; Halmagyi-Curthoys test
Purpose
Checks the horizontal vestibulo-ocular reflex (VOR) on each side for peripheral vestibular hypofunction.
Patient position
Sitting, facing the examiner, eyes fixed on the examiner’s nose.
Hold the head with both hands and tip it forward slightly.
Move it gently side to side so the patient relaxes the neck.
Make a small, fast, unpredictable turn to one side and stop.
Watch whether the eyes stay on target. Repeat several times each way, in random order.
Positive finding
A catch-up (corrective) saccade back to the target after the turn suggests reduced VOR on the side the head was turned toward.
Cautions
Avoid in acute neck injury, cervical instability, significant neck pain or recent neck surgery. Screen first for neck pain, recent neck trauma, cervical instability and vascular risk; stop and refer if the patient develops double vision, slurred speech, trouble swallowing, facial numbness, limb weakness or numbness, or loss of coordination. In a patient with new, constant vertigo, a normal head impulse test is not reassuring; see the HINTS note below.
Evidence notes
Some corrective saccades happen during the head turn and cannot be seen at the bedside, so a normal bedside test does not exclude hypofunction; the authors advise instrumented testing when the bedside test is unclear.[8]HINTS (head impulse, nystagmus, test of skew) is a three-step exam for acute vestibular syndrome (new, continuous vertigo with nystagmus) used by trained clinicians, typically in emergency settings. In 101 high-risk patients, a normal head impulse test, direction-changing gaze nystagmus or skew deviation was 100% sensitive and 96% specific for stroke.[10] It is not a test for episodic or positional dizziness, and physical therapists should not use it to rule out stroke. Refer acute vestibular syndrome or any central sign to emergency care.
Diagnostic accuracy
Target condition (source)
Sensitivity
Specificity
+LR
−LR
Peripheral hypofunction vs quantitative (search-coil) head impulse test, neuro-otology experts[8]
63%
78%
—
—
Video clips of 15 patients and 9 healthy people. Non-experts: sensitivity 72%, specificity 64%.
With the eyes closed (or behind goggles), shake the head briskly side to side for several seconds.
Stop suddenly, have the patient open the eyes and look straight ahead, and watch for nystagmus.
Positive finding
Horizontal nystagmus after shaking suggests asymmetric peripheral vestibular function. Vertical nystagmus after horizontal head shaking can point to a central problem and needs medical referral.
Cautions
Avoid in cervical instability, acute neck pain or recent neck injury. Screen first for neck pain, recent neck trauma, cervical instability and vascular risk; stop and refer if the patient develops double vision, slurred speech, trouble swallowing, facial numbness, limb weakness or numbness, or loss of coordination.
Evidence notes
Combined with spontaneous nystagmus and the head impulse test (“triple test”), see Combined bedside screens below.
Diagnostic accuracy
Target condition (source)
Sensitivity
Specificity
+LR
−LR
Caloric canal paresis greater than 20% (132 dizzy patients)[11]
66%
77%
—
—
Nystagmus was recorded with electronystagmography and Frenzel glasses, not by eye alone.
▶Video demonstration coming soonFilmed by Holsman physical therapists
Clinical dynamic visual acuity
Also called: Non-instrumented DVA; dynamic illegible E test
Purpose
Shows whether vision blurs during head movement, a functional sign of reduced VOR (oscillopsia).
Patient position
Sitting at the standard distance from an eye chart, wearing usual distance glasses.
Record the smallest line read with the head still.
Move the head side to side (or up and down) in a small, quick, steady rhythm, ideally paced with a metronome.
Record the smallest line read while the head is moving.
Note the number of lines lost.
Positive finding
Losing more lines during head movement than expected suggests reduced gaze stability, often from vestibular hypofunction.
Cautions
Keep head movements small. Avoid in cervical instability or acute neck pain. Use the same chart, lighting, distance and rhythm each time.
Evidence notes
The 2022 vestibular rehabilitation guideline lists clinical dynamic visual acuity among outcome measures for vestibular hypofunction.[3] We did not verify a sensitivity, specificity or line-loss cut-off, so we give none. Use it mainly to track change over time.
Diagnostic accuracy
Accuracy data not verified. We did not find a sensitivity and specificity study for this bedside test that we could check, so we show no numbers here.
▶Video demonstration coming soonFilmed by Holsman physical therapists
Bucket test (subjective visual vertical)
Also called: Bucket SVV test
Purpose
Estimates how a person perceives vertical, which reflects otolith (utricle) and central graviceptive pathways.
Patient position
Sitting, looking into a bucket that hides all visual cues, with a straight line drawn inside the bottom and a protractor or plumb line on the outside for the examiner.
Rotate the bucket to a random angle, out of the patient’s sight.
Turn it slowly until the patient says the line looks vertical.
Read the deviation from true vertical on the outside scale.
Repeat several times, starting in each direction, and average.
Positive finding
A larger tilt than in healthy people, especially soon after an acute vestibular event. Healthy adults in the original study averaged about 1° from true vertical.[13]
Cautions
Low-tech and safe, but not a stand-alone test; repeat measurements vary.
Evidence notes
In 30 healthy people and 30 with acute vestibular lesions, the bucket agreed closely with a laboratory dome test (intertest reliability 89% monocular, 90% binocular), and healthy deviation was 1.1 ± 0.7° monocular and 0.9 ± 0.7° binocular.[13] In a later study of 15 healthy adults, test-retest reliability of the bucket was poor.[14] We do not give a cut-off.
Diagnostic accuracy
Target condition (source)
Sensitivity
Specificity
+LR
−LR
Stroke among adults with acute dizziness in an emergency department (71 patients, 7 cerebrovascular)[12]
100%
38%
—
—
95% CI 59–100% (sensitivity) and 24–52% (specificity); positive predictive value 18%. Emergency setting only; not a stroke test for therapy clinics.
▶Video demonstration coming soonFilmed by Holsman physical therapists
Romberg and sharpened Romberg
Also called: Tandem Romberg; Romberg on foam
Purpose
Tests standing balance with vision removed; on foam, it leans more on vestibular input.
Patient position
Standing, shoes off, arms crossed; guard closely beside the patient.
Romberg: feet together, eyes open, then eyes closed, each for up to 30 seconds.[15]
Sharpened Romberg: heel-to-toe (tandem) stance, eyes open, then closed.
Foam: feet together on medium-density foam, eyes closed.[15]
Record time held or the first loss of position.
Positive finding
Clearly worse balance with the eyes closed than open (a positive Romberg) suggests reliance on vision, from sensory or vestibular loss. Short times on foam with the eyes closed support a vestibular contribution.
Cautions
High fall risk: guard closely, use a gait belt as needed, and keep a stable surface nearby.
Evidence notes
The 2022 guideline lists both the Romberg and sharpened Romberg among outcome measures.[3] We did not verify accuracy figures for the sharpened Romberg. For a structured sensory balance test, see the mCTSIB.
Mark the starting point of the laser in a relaxed, natural head posture.
With the eyes closed, the patient turns the head fully to one side and returns to the starting position as accurately as possible.
Measure the distance from the start point; repeat several times each direction and for extension.
Convert to degrees using the distance from the wall (angle = arctangent of error ÷ distance).
Positive finding
Consistently large errors in returning to neutral suggest impaired neck position sense.
Cautions
Avoid in acute neck injury or instability. Results also depend on pain and attention.
Evidence notes
The test was described in 30 people with neck pain vs 30 controls.[17] In whiplash, people with dizziness had larger errors after right rotation than those without (4.5° vs 2.9°).[18] People with cervicogenic dizziness were more likely than people with BPPV to have an error of about 4.5°.[19] In chronic dizziness, joint position error after extension raised the odds of cervicogenic dizziness (OR 1.52), but its best cut-off had low specificity.[20] No sensitivity or specificity is shown, because we could not verify them.
Diagnostic accuracy
Accuracy data not verified. We did not find a sensitivity and specificity study for this bedside test that we could check, so we show no numbers here.
▶Video demonstration coming soonFilmed by Holsman physical therapists
Seated cervical rotation (torsion) test
Also called: Cervical torsion test; head-fixed trunk rotation
Purpose
Helps separate neck-driven (cervicogenic) dizziness from vestibular dizziness by rotating the trunk under a still head.
Patient position
Sitting on a swivel chair with a backrest; eyes closed or behind goggles; the examiner stands behind.
In torsion: the examiner holds the head still while the patient uses the feet to turn the chair and trunk at least 45° to one side, holding 30 seconds; then the other side.[21]
En bloc: the head and trunk turn together the same amount and hold.[21]
Ask about dizziness and watch for nystagmus during and right after each position.
Positive finding
Symptoms or nystagmus in torsion but not en bloc suggest a neck contribution; symptoms en bloc suggest a vestibular cause, because the inner ear moves only in that version.
Cautions
Sustained neck rotation can be provocative. Screen first for neck pain, recent neck trauma, cervical instability and vascular risk; stop and refer if the patient develops double vision, slurred speech, trouble swallowing, facial numbness, limb weakness or numbness, or loss of coordination.
Evidence notes
Symptoms in torsion rose with neck disability in the same study.[21] With video recording, more than 2°/s of nystagmus during cervical rotation was more common in cervicogenic dizziness than in BPPV.[19] Cervicogenic dizziness remains a diagnosis of exclusion.
Diagnostic accuracy
Target condition (source)
Sensitivity
Specificity
+LR
−LR
Peripheral vestibular hypofunction vs healthy controls, in torsion (19 vs 19)[21]
32%
95%
6.00
0.72
This shows the test rarely provokes symptoms in vestibular hypofunction; it is not an accuracy figure for cervicogenic dizziness. En bloc: sensitivity 26%, specificity 95%.
▶Video demonstration coming soonFilmed by Holsman physical therapists
Combined bedside screens
Combinations of findings usually tell you more than one test alone.
Triple test (spontaneous nystagmus, head-shaking nystagmus, head impulse)
Items: Any one abnormal counts as positive; screens for one-sided weakness on caloric testing in recent vertigo.
Accuracy: For unilateral weakness of 25% or more: sensitivity 63.6%, specificity 85.4%, negative predictive value 80.4%. For 50% or more: sensitivity 81.8%, specificity 81.4%, negative predictive value 94.1% (151 patients).[22]
Items: Head impulse test, nystagmus in different gaze directions, and test of skew (alternate cover test).
Accuracy: A normal head impulse test, direction-changing gaze nystagmus or skew deviation was 100% sensitive and 96% specific for stroke in 101 high-risk patients; early MRI missed 12% of strokes.[10]
HINTS is listed here for context. It is for new, continuous vertigo, is done by trained clinicians, usually in emergency settings, and is not a reason to keep a patient with central signs in the clinic.
Related balance and gait tools
After the bedside exam, these measures help quantify balance and gait and track progress:
How we grade sources.A = clinical practice guideline, systematic review or critically appraised topic. B = single prospective diagnostic study. C = small, retrospective, case-control, reliability or normative study. R = professional review resource. D = expert clinical opinion (our test descriptions). Every accuracy number on this page was checked against the cited abstract or full text on November 14, 2026. If we could not check a number, we left it out and say “accuracy data not verified.”
Grade R Academy of Neurologic Physical Therapy. Vestibular EDGE task force outcome measure recommendations. Not reproduced here; see the Academy’s website. neuropt.org
Grade A Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3 suppl):S1-S47. doi:10.1177/0194599816689667 (full text). doi:10.1177/0194599816689667
Grade A Hall CD, Herdman SJ, Whitney SL, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: an updated clinical practice guideline from the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022;46(2):118-177. doi:10.1097/NPT.0000000000000382 (full text). PMC8920012
Grade A Halker RB, Barrs DM, Wellik KE, Wingerchuk DM, Demaerschalk BM. Establishing a diagnosis of benign paroxysmal positional vertigo through the Dix-Hallpike and side-lying maneuvers: a critically appraised topic. Neurologist. 2008;14(3):201-204. doi:10.1097/NRL.0b013e31816f2820 (abstract). PubMed 18469678
Grade B Cohen HS. Side-lying as an alternative to the Dix-Hallpike test of the posterior canal. Otol Neurotol. 2004;25(2):130-134 (abstract). PubMed 15021771
Grade C Choung YH, Shin YR, Kahng H, Park K, Choi SJ. “Bow and lean test” to determine the affected ear of horizontal canal benign paroxysmal positional vertigo. Laryngoscope. 2006;116(10):1776-1781 (abstract). PubMed 17003735
Grade B Lee JB, Han DH, Choi SJ, et al. Efficacy of the “bow and lean test” for the management of horizontal canal benign paroxysmal positional vertigo. Laryngoscope. 2010;120(11):2339-2346 (abstract). PubMed 20938976
Grade B Jorns-Häderli M, Straumann D, Palla A. Accuracy of the bedside head impulse test in detecting vestibular hypofunction. J Neurol Neurosurg Psychiatry. 2007;78(10):1113-1118 (abstract; erratum 2008). PMC2117540
Grade B Perez N, Rama-Lopez J. Head-impulse and caloric tests in patients with dizziness. Otol Neurotol. 2003;24(6):913-917 (abstract). PubMed 14600474
Grade B Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-3510 (abstract). PMC4593511
Grade B Iwasaki S, Ito K, Abbey K, Murofushi T. Prediction of canal paresis using head-shaking nystagmus test. Acta Otolaryngol. 2004;124(7):803-806 (abstract). PubMed 15370565
Grade B Shaban A, Zafar A, Borte B, et al. The bucket test improves detection of stroke in patients with acute dizziness. J Emerg Med. 2021;60(4):485-494 (abstract). PubMed 33308916
Grade C Zwergal A, Rettinger N, Frenzel C, Dieterich M, Brandt T, Strupp M. A bucket of static vestibular function. Neurology. 2009;72(19):1689-1692 (abstract). PubMed 19433743
Grade C Michelson PL, McCaslin DL, Jacobson GP, et al. Assessment of subjective visual vertical (SVV) using the “bucket test” and the Virtual SVV System. Am J Audiol. 2018;27(3):249-259 (abstract). PubMed 29946701
Grade C Cohen HS, Mulavara AP, Peters BT, Sangi-Haghpeykar H, Bloomberg JJ. Standing balance tests for screening people with vestibular impairments. Laryngoscope. 2014;124(2):545-550 (full text). PMC3841227
Grade C Jacobson GP, McCaslin DL, Piker EG, et al. Insensitivity of the “Romberg test of standing balance on firm and compliant support surfaces” to the results of caloric and VEMP tests. Ear Hear. 2011;32(6):e1-e5 (abstract). PubMed 21775891
Grade C Revel M, Andre-Deshays C, Minguet M. Cervicocephalic kinesthetic sensibility in patients with cervical pain. Arch Phys Med Rehabil. 1991;72(5):288-291 (abstract). PubMed 2009044
Grade C Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med. 2003;35(1):36-43 (abstract). PubMed 12610847
Grade C L’Heureux-Lebeau B, Godbout A, Berbiche D, Saliba I. Evaluation of paraclinical tests in the diagnosis of cervicogenic dizziness. Otol Neurotol. 2014;35(10):1858-1865 (abstract). PubMed 25058834
Grade C De Vestel C, Vereeck L, Van Rompaey V, Reid SA, De Hertogh W. Clinical characteristics and diagnostic aspects of cervicogenic dizziness in patients with chronic dizziness: a cross-sectional study. Musculoskelet Sci Pract. 2022;60:102559 (abstract). PubMed 35364427
Grade C Nüesch A, Treleaven J, Ernst MJ. Validation of the cervical torsion test and head-neck differentiation test in patients with peripheral vestibular hypofunction. Phys Ther. 2024;104(7):pzae057 (full text). PMC11272218
Grade B Rohrmeier C, Richter O, Schneider M, et al. Triple test as predictive screen for unilateral weakness on caloric testing in routine practice. Otol Neurotol. 2013;34(2):297-303 (abstract). PubMed 23444477
Grade D Holsman Physical Therapy clinical guidance. Patient position, test steps and positive findings written in our own words by Holsman physical therapists and reviewed by Dr. Richard Holsman, PT, DPT, NCS. Expert opinion, not a research source.
Reviewer
Reviewed by Dr. Richard Holsman, PT, DPT, NCS (Board-Certified Clinical Specialist in Neurologic Physical Therapy), founder of Holsman Physical Therapy. Last reviewed: November 14, 2026.
Change log
November 14, 2026: Page published. Test descriptions written in our own words; accuracy values checked against the cited sources.
Review policy
We re-check every number on this page against its source at least once a year, and sooner if a source is updated, a better study is published or a reader reports a problem. Changes are listed in the change log with the date. To report an error, contact us.
Licensing
Test descriptions, steps and the accuracy summaries are original text by Holsman Physical Therapy. Accuracy values are individual numbers cited with credit to the original studies; no tables, figures or text from journals, textbooks or other websites are reproduced. Linking to a source does not imply its endorsement. Demonstration videos, when added, will be filmed by Holsman physical therapists with consenting adult models.
Conflict of interest and advertising
This page is published by Holsman Physical Therapy and Wellness, P.C., which runs outpatient and in-home therapy practices; that is our only commercial interest. The page carries no advertising, no sponsorship and no affiliate links, and we received no payment from any source for it. Holsman Physical Therapy is not affiliated with the authors or publishers cited, and they do not endorse this website.
For clinician education; bedside vestibular tests support, but do not replace, a full examination and medical diagnosis. A positive or negative test changes the probability of a condition; it does not make a diagnosis. Interpret every result with the history, the rest of the examination, imaging when indicated, and clinical judgment. Stop any test that provokes severe pain or neurological symptoms.
Common Questions
What is the best bedside test for BPPV?
The Dix-Hallpike test is the standard test for posterior canal BPPV, the most common type. If it shows horizontal or no nystagmus in someone with a typical history, the supine roll test checks for horizontal canal BPPV. The side-lying test is an alternative when the Dix-Hallpike position is not safe or possible.
What is the difference between geotropic and apogeotropic nystagmus?
In the supine roll test, geotropic nystagmus beats toward the floor on both sides and the stronger side is usually the affected ear. Apogeotropic nystagmus beats toward the ceiling on both sides and the affected ear is usually opposite the stronger side.
Can a physical therapist use HINTS to rule out a stroke?
No. HINTS was studied in acute vestibular syndrome in emergency settings with trained examiners. Physical therapists do not diagnose stroke. Any central sign, such as double vision, slurred speech, new weakness or numbness, or a new severe headache, needs emergency care.
Can physical therapy help vertigo and dizziness?
Often, yes. BPPV usually responds to canalith repositioning maneuvers, and clinical practice guidelines support vestibular rehabilitation for people with inner-ear hypofunction. A trained clinician should examine you first to find the cause.
Referring a Patient?
Holsman physical therapists see patients at clinics across North Jersey, the Bronx and Brooklyn, plus in-home visits.
