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Unraveling the complexity: A guide to vestibular assessment

5 min read. Posted in Head
Written by Elsie Hibbert info

Dizziness is the most common complaint from people over 75 years old when presenting to General Practitioners (1). This is all well and good as being ‘General’ Practitioners, they are well equipped to screen for the myriad of dizziness causes, from pharmaceutical side-effects to serious cardiac conditions. As physios, it can be a bit tricky when presented with a dizziness case as a primary practitioner – you need to figure out if it’s something you can treat or whether you need to refer on, and if you do think you’re the right right person to treat it, what treatment path do you go down? Those of us who don’t routinely see vestibular-related dizziness in clinic will often find ourselves thinking ‘I’ve really got to do another vestibular refresher’ whenever presented with the odd vestibular case, especially if it’s not just Benign Paroxysmal Positional Vertigo (BPPV)! So without further ado, here’s a fresh injection of vestibular assessment info from Vanessa Simpson’s Vestibular Dysfunction Masterclass.

If you’d like to up your game and learn how expert physios assess and treat vestibular dysfunction, watch Vanessa’s full Masterclass HERE.



Subjective assessment

It’s all about the questioning people! Obviously, as always, include your usual line of questioning as you would with any new patient (particularly noting past medical history here e.g. cardiac). Subjective questioning is integral to get a good understanding of the patient’s symptoms; interestingly, Vanessa notes the importance of subjective questioning for identifying potential Vertebrobasilar Insufficiency (VBI), due to the poor specificity and sensitivity of objective VBI testing. Here are a few specific questions Vanessa notes in her Masterclass:

  • What do you mean by dizziness? (i.e. true room spin, lightheaded, or like they’re going to faint?)
  • When did it start?
  • 5 D’s – dizziness AND diploplia, dysphagia, dysarthria, drop attacks
  • How long do your symptoms last? (BPPV is brief)
  • How often does it occur?
  • What triggers it? (e.g. movement-related?)
  • Are they experiencing changes in balance?
  • Does darkness or uneven ground affect them?
  • Are they experiencing oscillopsia (when still objects appear to jump/vibrate)
  • Are they experiencing any new headaches?
  • Are they experiencing motion sensitivity? Do they have a history of motion sensitivity?
  • Are they experiencing any changes in vision or hearing?
  • How are their symptoms affecting their activity participation?
  • What medications are they on/have they been on recently?


Objective assessment

WIth a thorough subjective assessment under your belt, you will (hopefully) have more of a clue as to what might be going on and prioritise your objective assessments accordingly. Below is a list of assessments which Vanessa routinely uses:

  • Heart rate/blood pressure
  • Strength, sensation, coordination and speech screening
  • Oculomotor assessment
  • Head Impulse, Nystagmus, Test of Skew (HINTS) test*
  • Positional tests (e.g. Dix-Hallpike)
  • Head impulse test
  • Dynamic visual acuity
  • Balance and functional gait assessments

*The HINTS exam is reported to have high sensitivity and specificity for the presence of a central cause of vertigo, and is more sensitive than early MRI for detecting stroke (2).


For an in-depth understanding of how the experts conduct these tests, watch Vannessa’s full Masterclass. She also provides great insight into differentiating between central and peripheral vestibular problems, see below for the key differences she outlines:


  • Nystagmus more likely: direction changing, enhanced with fixation, vertical or pure rotational, vertical if provoked post-head shake
  • Smooth pursuit and saccade likely abnormal
  • Common other neurological symptoms (5 D’s), but not always
  • Severe imbalance
  • Moderate nausea
  • Hearing loss rare
  • Highly unlikely to get true vertigo (more likely lightheadedness)


  • Nystagmus more likely: direction fixed, present with fixation removed, follows Alexander’s law, provoked post-head shake
  • Smooth pursuit and saccade normal/age appropriate
  • Abnormal Vestibulo-Ocular Reflex (VOR)
  • Mild imbalance
  • Severe nausea
  • Potential hearing loss
  • More likely to get true vertigo


Peripheral vestibular dysfunction

Okay, let’s delve deeper into those peripheral vestibular problems. Peripheral vestibular dysfunction is present in about 40% of dizzy patients (3), and is characterised by damage to the vestibular or inner ear balance system resulting in vestibular hypofunction of one or both sides.


Objective assessment of peripheral vestibular loss

  • Oculomotor assessment
  • Positional testing (can have BPPV in addition to vestibular loss)
  • Head impulse testing
  • Dynamic visual acuity testing
  • Head shaking nystagmus test
  • Clinical Test of Sensory Interaction of Balance (CTSIB)
  • Functional gait testing

Unilateral vestibular dysfunction/loss

Causes: vestibular neuritis, labyrinthitis, Ramsay-Hunt Syndrome, acoustic neuroma, Meniere’s disease, Traumatic Brain Injury (TBI), age-related degeneration.

Acute signs and symptoms:

  • Vertigo
  • Nausea
  • Unsteadiness
  • Can persist for a few days
  • Can persist with eyes closed
  • Positive head impulse test to one side
  • Horizontal nystagmus toward unaffected ear

Subacute signs and symptoms (brain begins to compensate):

  • Lightheaded/spacey/disorientated rather than vertigo
  • Nystagmus reduces
  • Blurring on rapid head movement

Bilateral vestibular dysfunction/loss

Causes: gentamicin (antibiotic) use, idiopathic, sequential neuritis (one side affected and then the other), meningitis, TBI, age-related degeneration.

Signs and symptoms:

  • No vertigo or nystagmus (if total loss, as no asymmetrical signals)
  • Oscillopsia
  • Very unsteady
  • Lightheaded
  • Positive head impulse test bilaterally (due to loss of VOR)


Wrapping up

There you have it, an overview on the assessment and differentiation between central and peripheral vestibular problems. Just remember, it is most important to get a thorough subjective history of your patient’s dizziness in order to guide your decision-making. For all those musculoskeletal physios out there, hopefully you’ll feel more confident next time a non-cervicogenic dizziness patient finds their way into your clinic!

Vestibular problems can be a tricky business, learn the ins-and-outs of how expert physio Vanessa Simpson assesses and treats vestibular dysfunction in her Masterclass, watch HERE.

Want to become more confident treating vestibular disorders?

Vanessa Simpson has done a Masterclass lecture series for us!

“Vestibular Dysfunction: From Assessment to Rehabilitation”

You can try Masterclass for FREE now with our 7-day trial!

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