This video is taken from a BMJ Learning module on Vertigo.
This manoeuvre is used as a diagnostic test, used particularly when you suspect benign paroxysmal positional vertigo
You should explain the procedure to the patient, and warn them that they may experience vertigo symptoms during it, but that the symptoms usually subside quickly. You should ask them to keep their eyes open throughout and stare at your face. Check that the patient does not have any neck injuries or other contraindications to rapid spinal movements
Ask the patient to sit on an examination couch with their legs extended, close enough to the edge so that their head will hang over when they are laid flat
Stand on their left side, take hold of their head with both your hands, and turn their head 45° towards you. (This tests the left posterior canal). Observe their eyes for 30 seconds. (Signs and symptoms usually occur when you turn the patient's head towards the lesion - if you suspect disease of the right ear, you may wish to start on their right side.) The authors recommend starting with the non-affected side
Keeping the patient's head in the same position, lie them down quickly until their head is hanging over the edge of the couch (still turned 45° towards you) Observe their eyes for 30 seconds
Lift the patient back up to sitting position, and repeat the test on their right side
In a patient with BPPV, you will typically see a characteristic pattern of nystagmus emerge after 5-20 seconds, when the patient's head is hanging towards the side of the lesion. This is called torsional or rotatory nystagmus and has two components: a quick movement towards the side of the lesion and a slow component away from it. An upward beating nystagmus is often superimposed on this movement.
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Benign paroxysmal positional vertigo is an amazing condition. The reason why is when you see a patient with vertigo you can perform a manoeuvre which will make the diagnosis. Then you can perform another manoeuvre which will fix them.
When doing the Dix-Hallpike manoeuvre, I always go through with the patient what I'm about to do. I do this regularly, but to a patient, this is something that's very new and it can be a little bit scary for them. Something I find useful is for the patient to fold their arms before I do the Dix-Hallpike manoeuvre. The patient's head is turned 45 degrees towards me. They're then lowered backwards so that their head is extended about 20 degrees over the back of the couch.
If a patient has benign paroxysmal positional vertigo, you will often see then within 20 to 30 seconds. Occasionally nystagmus will be seen up to a minute after their head has been extended. In view of this, if you really do feel that there's a strong history that would be suggestive of benign paroxysmal positional vertigo, it's often worthwhile holding the head back in the extended position for up to a minute.
When lowering the patient back, if they do have benign paroxysmal positional vertigo, they can find this very traumatic. If they do find it traumatic they can close their eyes very tightly. This makes it very difficult to assess any eye movements. To stop patients from closing their eyes, I explain to them that it's very important that they keep their eyes open. Sometimes I ask patients to look at my nose whilst I lower their head down.
It is important to perform the Dix-Hallpike manoeuvre with the head over the left and right lateral positions. I usually perform the Dix-Hallpike manoeuvre on the side that is asymptomatic first.