Vestibular —
Training activity: 2

Details

Safely perform the following diagnostic tests and select and perform appropriate repositioning manoeuvres based on the findings:

• Dix-Hallpike test
• Rose test
• Horizontal roll test

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Principles of patient-centred care
• Atypical test findings
• Onward referral pathways for non-routine or difficult-to-treat cases, or those with central findings
• Alternative repositioning manoeuvres
• Local, national, international guidelines and standards

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like?
  • What are the indicators of successfully and safely performing these specific positional and selection manoeuvres?
  • What are the criteria for selecting the appropriate manoeuvre based on findings?
  • Have you discussed expectations for patient safety and technique with your training officer?
• What is your prior experience of this activity?
  • Have you performed these specific positional and repositioning manoeuvres before?
  • What do you already know about the safety protocols required for rapid positional changes or managing patient anxiety/nausea?
  • What specific challenges related to patient mobility, distinguishing subtle nystagmus, or performing the physical technique accurately might you face. How might you plan to handle them?
  • What is the scope of your own practice for performing and selecting these manoeuvres? When will you need to seek advice or help (e.g., if a procedure is contraindicated), and from whom?
  • How do you feel about performing these physical manoeuvres?
• What do you anticipate you will learn from the experience?
  • What specific skills in technique, patient management during positional changes, or interpretation of observed nystagmus do you want to develop or refine, drawing upon previous experiences?
  • What specific insights into the mechanism of BPPV and the principles of successful repositioning do you hope to gain?
• What additional considerations do you need to make?
  • Have you reviewed any actions identified from your previous reflections on performing physical tests?
  • Do you need to check the room setup, ensure appropriate assistance (if required), or review safety guidelines for patient physical limitations before starting?

In action

• During the activity is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate during the performance of a diagnostic test or manoeuvre? Are you encountering situations such as:
    • A patient experiencing unexpected, severe vertigo or nausea during the positioning tests, impacting their tolerance?
    • The nystagmus characteristics (timing, direction, duration) being ambiguous or atypical for the manoeuvre performed?
    • Difficulty with patient positioning (e.g., due to limited mobility or neck pain) that requires significant adaptation of the standard protocol?
    • The patient showing extreme anxiety or panic related to the movement involved in the manoeuvre?
  • How does this experience compare with previous experiences of similar activities?
• How are you reacting to the unexpected development?
  • How is the unexpected development being resolved as you progress during the activity? Are you successfully managing the situation yourself, or do you need support (e.g., medical intervention for extreme nausea)?
  • What are you learning in this moment as a result of the unexpected development? For example, are you learning effective communication techniques to manage patient anxiety during movement, or gaining a deeper understanding of how subtle nystagmus responses inform the differential diagnosis?
  • How is this impacting your actions?
    • Are you responding to the situation appropriately (e.g., prioritising patient safety and comfort)? Are you adapting or changing your approach to the manoeuvre (e.g., slowing down the head turn, adjusting the drop)?
    • Is this unexpected event affecting your ability to undertake the activity independently?
    • Specifically, are you immediately confirming the nystagmus characteristics to select the appropriate repositioning manoeuvre?
  • How are you feeling in this moment? For example, are you finding it difficult to adapt? Is it affecting your confidence in performing quick, decisive positioning? Are you feeling positive you can reach a successful conclusion?
• What is the conclusion or outcome?
• • How are you working within your scope of practice? E.g. Are you successfully performing the manoeuvre, prioritising patient safety and adapting positioning for tolerance, ensuring you adhere to standard protocols? Are you working within your scope by accurately interpreting the nystagmus characteristics (timing, direction) to confirm the canal involved and selecting the appropriate repositioning manoeuvre?
  • What do you learn as a result of the unexpected development? E.g. Are you learning effective communication techniques to manage patient anxiety and unexpected vertigo during the manoeuvre? Are you gaining a deeper understanding of how subtle nystagmus responses inform the differential diagnosis?

On action

• What happened?
  • Begin by summarising the key steps you took to perform the diagnostic tests (Dix-Hallpike, Rose, Horizontal roll) and the selection and performance of appropriate repositioning manoeuvres.
  • Consider specific events, actions, or interactions that felt important, such as ensuring patient safety during positioning, the elicitation of nystagmus, or managing patient anxiety. How did you feel during the testing or manoeuvre?
  • Include any ‘reflect-in-action’ moments, where you had to adapt your technique or approach based on unexpected patient responses or immediate findings.
• How has this experience contributed to your developing practice?
  • What learning can you take from performing this specific test or manoeuvre?
  • What strengths did you demonstrate in safely performing the activity and selecting the manoeuvre? What skills or knowledge gaps were evident (e.g., related to technique, interpretation, patient comfort)?
  • How did this experience compare against previous engagements with similar activities? Were any previous identified actions for development achieved? Has your practice improved?
  • Identify any challenges you experienced (e.g., patient positioning, eliciting nystagmus, interpreting responses, patient anxiety) and how you reacted to these. Did these challenges affect your ability to deal with the situation? Were you able to overcome them?
  • Was there anything significant about this activity, such as needing to seek advice or clarification on technique or findings, or considering if you were working within your scope of practice
• What will you take from this experience moving forward?
  • Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you received.
  • What will you do differently next time you perform this test or manoeuvre?
  • Has anything changed in terms of what you would do if you were faced with a similar situation again?
  • Do you need to practise any aspect of performing or selecting these tests/manoeuvres further? E.g.
    • The precise timing and positioning of the Dix-Hallpike and Horizontal roll tests to reduce patient discomfort and optimise nystagmus observation.
    • Reviewing the criteria for selecting the appropriate repositioning manoeuvre based on subtle nystagmus characteristics, especially in the presence of ambiguous findings.
    • Implementing clearer verbal cues and distraction techniques to enhance patient safety and comfort during rapid positional changes.
    • Seeking immediate feedback on your technique for eliciting and interpreting nystagmus patterns during positional testing.

Beyond action

• Have you revisited the experiences?
  • Have you revisited your previous reflections (reflect-before-action, reflect-in-action, and reflect-on-action) for this specific activity (performing positional tests and repositioning manoeuvres)?
  • When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to achieving precise patient positioning, ensuring patient safety and comfort, accurately observing nystagmus, or selecting the correct manoeuvre based on findings?
  • Have you completed these previously identified actions? If not, what are the barriers? If so, how did completing them impact your subsequent performance of this activity? Are you ready to demonstrate this new learning confidently and consistently when performing this task?
  • Have you engaged in professional storytelling or discussed your experiences of these tests and manoeuvres with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of the nuances of nystagmus interpretation or strategies for managing highly anxious patients during rapid movements?
•  How have these experiences impacted upon current practice?
  • Considering your cumulative experiences and reflections on this activity, how will the learning you have gained support you in preparing for relevant observed ‘in-person’ assessments for the module?
  • How has your practice related to safely performing diagnostic tests and selecting/performing appropriate repositioning manoeuvres developed and evolved over time across multiple instances of undertaking this ETA? Can you identify specific examples of improvement or increased confidence in swiftly identifying the affected canal, maintaining patient trust, or handling unexpected clinical signs?
  • Based on your experiences, how has your ability to recognise when something related to positional testing is beyond your scope of practice improved? Do you have a clearer understanding of when and from whom (e.g., supervisor, neurologist, physiotherapy specialist) you need to seek advice or clarification regarding unusual positional vertigo (e.g., non-fatiguing), complex nystagmus patterns, or contraindications to certain manoeuvres?

Relevant learning outcomes

#	Outcome
# 3	Outcome Perform and interpret a wide range of diagnostic vestibular tests.
# 5	Outcome Provide safe and effective vestibular rehabilitation for commonly occurring disorders in patients without significant comorbidities.