Loaded Dix-Hallpike Test

Screenshot 2025-06-27 074334

Fundamentals 

The loaded Dix-Hallpike (L-DH) is a positional test used to improve diagnostic sensitivity for posterior canal BPPV, particularly in cases where the standard Dix-Hallpike test may seem normal, yet posterior canal BPPV is actually present. 

The test involves preloading the posterior canal by holding the seated patient’s head in a flexed and rotated position toward the side to be tested for 30 seconds before moving into the traditional Dix-Hallpike test. The flexed position of the neck is meant to consolidate dispersed otoconia in the long arm of the posterior canal, moving them toward the ampulla where the cupula is located. Subsequently, the clumped otoconia have a greater distance to travel away from the cupula when in the Dix-Hallpike position, increasing the likelihood of provoking the nystagmus and symptoms consistent with posterior canal BPPV when it is present. 

In Andera et al.’s study, the loaded Dix-Hallpike test demonstrated a higher sensitivity (95.2%) compared to the standard Dix-Hallpike test (82.1%). Clinicians should be aware that the L-DH may provoke stronger symptoms in some patients, so the decision to use this version of the Dix-Hallpike should be made on a case-by-case basis.

History

luke-andera-md

Dr. Luke Andera

890336_327656

Dr. Jeffrey Walter, PT

The Loaded Dix-Hallpike test was first described in 2020 by a group of otolaryngologists along with a specialized physical therapist at Geisinger Medical Center in Pennsylvania, USA.

Further studies utilizing the Loaded Dix-Hallpike will be useful when available. A 2025 study by authors including Dr. Susan Whitney noted that responses to the Dix-Hallpike test, including variations like the L-DH, are influenced by factors such as gaze direction and measurement techniques. Indeed, there are many aspects to consider when seeking to optimize accurate diagnosis of BPPV.

 

Instructions

The goal of the loaded Dix-Hallpike test is to provoke characteristic symptoms and nystagmus associated with displaced otoconia within the affected posterior semicircular canal. The left and right sides must be tested individually.

Right Ear

  1. Explain the procedure to the patient and obtain consent.
  2. Position the patient in long-sitting on the exam table and instruct the patient to keep their eyes open throughout the test.
  3. Have the patient turn their head 45 degrees to the right and flexed forward 30 degrees in the plane of the posterior canal. Keep them in this position for 30 seconds.
  4. Keep the head to the right, support the head and guide the patient quickly into a supine position with the head extended 20° with the patient’s shoulders resting on a surface (table, bed, or pillow).
  5. Observe the patient’s eyes for nystagmus and ask about vertigo symptoms.
  6. Hold this position at least 30 to 60 sec.
  7. If not moving into treatment from the testing position, assist the patient back to sitting, maintaining head rotation to the right.
  8. Monitor for vertigo and nystagmus during return to sitting and continue to guard the patient.

Left Ear

  1. Explain the procedure to the patient and obtain consent.
  2. Position the patient in long-sitting on the exam table and instruct the patient to keep their eyes open throughout the test.
  3. Have the patient turn their head 45 degrees to the left and flexed forward 30 degrees in the plane of the posterior canal. Keep them in this position for 30 seconds.
  4. Keep the head to the left, support the head and guide the patient quickly into a supine position with the head head extended 20° with the patient’s shoulders resting on a surface (table, bed, or pillow).
  5. Observe the patient’s eyes for nystagmus and ask about vertigo symptoms.
  6. Hold this position for 30 to 60 seconds.
  7. If not moving into treatment from the testing position, assist the patient back to sitting, maintaining head rotation to the left.
  8. Monitor for vertigo and nystagmus during return to sitting and continue to guard the patient.

Test Interpretation

A classic abnormal loaded Dix-Hallpike test consistent with posterior canalithiasis type BPPV is characterized by a few seconds latency period followed by a burst of nystagmus lasting under 1 minute typically accompanied by symptoms. The classic direction of posterior canal nystagmus is upward and torsional toward the affected side. This response generally diminishes in intensity with repeated testing (fatigability). Nystagmus that matches with classic features of posterior canalithaisis type BPPV supports that diagnosis and informs appropriate treatment planning.

Example of nystagmus seen during an abnormal loaded Dix-Hallpike for the right ear:

Related Pathology

  • Posterior Canalithiasis
  • Posterior Cupulolithiasis

The loaded Dix-Hallpike test is best done with infrared video goggles due the risk of otherwise missing about 2/3 of abnormal eye movements when testing in room light or with traditional thickened lens Frenzels. See what you’re missing – access a free virtual demo (on-demand or live with a clinician) today.

Sources