The purpose of the HSN test is to identify peripheral vestibular dysfunction. Rapid head shaking and abrupt stopping may elicit nystagmus in patients with vestibular imbalance.
1
Less than 2 minutes
Children
6 - 12
yearsAdolescent
13 - 17
yearsAdult
18 - 64
yearsElderly Adult
65 +
yearsInitially reviewed by Jennifer Stoskus, PT, MSPT, DPT; Matthew Scherer PT, PhD, NCS and the Vestibular EDGE task force of the Neurology section of the APTA.
Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.
For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations
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Abbreviations: |
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HR |
Highly Recommend |
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R |
Recommend |
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LS / UR |
Reasonable to use, but limited study in target group / Unable to Recommend |
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NR |
Not Recommended |
Recommendations for use based on acuity level of the patient:
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Acute (CVA < 2 months post) (SCI < 1 month post) (Vestibular < 6 weeks post) |
Subacute (CVA 2 to 6 months) (SCI 3 to 6 months) |
Chronic (> 6 months) (Vestibular > 6 weeks post) |
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Vestibular EDGE |
LS |
|
LS |
Recommendations based on vestibular diagnosis
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Peripheral |
Central |
Benign Paroxysmal Positional Vertigo (BPPV) |
Other |
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Vestibular EDGE |
LS |
LS |
NR |
NR |
Recommendations for entry-level physical therapy education and use in research:
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Students should learn to administer this tool? (Y/N) |
Students should be exposed to tool? (Y/N) |
Appropriate for use in intervention research studies? (Y/N) |
Is additional research warranted for this tool (Y/N) |
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Vestibular EDGE |
No |
Yes |
No |
Yes |
Patient should be cleared of vascular and orthopedic contraindications (i.e. vertebral artery integrity and cervical stability) and demonstrate full, pain-free active range of motion in the plane of testing.
The HSN test provides information regarding peripheral vestibular system imbalance
Sensitivity of the HSN test improves as vestibular imbalance increases between R/L sides (as indicated with caloric testing)
Many studies of HSN use ENG equipment or a scleral search coil, which is not utilized in most clinical settings; few studies look at psychometrics using infrared lenses or Frenzel glasses, however this equipment is most commonly used in current clinical practice.
Methods used in older studies included the patient actively shaking his/her head, while common current practice, it is recommended that the clinician perform a passive head shake in order to ensure appropriate head position, velocity of headshaking, and stillness of the head after headshaking.
Overall recommendation: The HSN test is a brief test that can be added to a clinicians testing battery, however should not be used as a stand alone test; there is higher likelihood of vestibular dysfunction when both the HSN test and Head Impulse Test are both abnormal.
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Predictive Validity
Vestibular Tone Imbalance:
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Study |
n = number studied |
Mean Age (years) |
Sensitivity |
Specificity |
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Asawavichiangianda et al, 1997 |
300 Organic Vestibular including central = 198 Non-organic = 57 Psychogenic = 57 Unknown = 45 |
Total mean age = 48.4 |
31.7% |
Not reported |
|
Asawavichiangianda et al, 1999 |
1364 Control = 50 |
50.2% in pts with > 20% difference in canal excitability |
73.2% in pts with > 20% difference in canal excitability |
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Burgio et al, 1991 |
115: UVL = 25 BVL = 10 Dizziness with normal ENG = 80 Control =17 |
Not reported |
UVL = 44% BVL = 40% Dizziness with normal ENG = 50% |
Not reported |
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Fujimoto et al, 1993 |
1364 |
48.2 |
50.21% in pts with > 20% difference in canal excitability |
73.18% in pts with > 20% difference in canal excitability |
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Goebel and Garcia, 1992 |
214 |
55 |
42% Positive Predictive Value = 44% |
85% Negative Predictive Value = 84% |
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Hain et al, 1987 |
13: 6 s/p acoustic neuroma resection, 7 controls |
Not reported |
100% |
0% |
|
Harvey et al, 1997 |
105 |
52.1 |
35% Positive Predictive Value = 50% |
92% Negative Predictive Value = 86% |
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Jacobson et al, 1990 |
116 |
Not reported |
27% |
85% |
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Kamei, 1988 |
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Takahashi et al, 1990 |
85 |
44 ±10.2 |
83% |
Not reported- 29%? |
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Tseng and Chao, 1997 |
258 |
14-79 |
90% |
53% |
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Vincini et al, 1989 |
277 |
47.3 |
44% in peripheral dysfunction 22.5% central vestibular dysfunction |
Not reported |
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Wei et al, 1989 |
108 |
49 ±18 |
32% Positive Predictive Value = 32% |
60% Negative Predictive Value = 75% |
Tseng (1997) reported the head-shaking nystagmus test a sensitive measure to predict vestibular tone imbalance with canal paresis set to at least 20%.
Vestibular Dysfunction:
Asawavichianda et al. (1997) reported a higher incidence of HSN in patients with peripheral dysfunction. Also that caloric testing and HSN correlated well with peripheral dysfunction than other tests on ENG, and there is a greater chance of HSN or strong HSN if there is vestibular nerve involvement.
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Sensitivity of Head Shaking Nystagmus in Patients with Peripheral Vestibular Dysfunction
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Diagnosis |
n = number studied |
HSN (+) |
Sensitivity |
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Meniere’s |
31 |
18 |
58.1 |
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Acoustic neuroma |
21 |
10 |
47.6 |
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Vestibular neuronitis |
8 |
4 |
50.0 |
|
Recurrent vestibulopathy |
26 |
9 |
30.8 |
|
BPPV |
63 |
18 |
28.6 |
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Other |
16 |
5 |
31.4 |
|
Unknown |
27 |
12 |
44.4 |
Incidence of HSN in patients/controls with vestibular asymmetry of 20% or less = 56% Hall et al, 1991: (n = 360, 340 with vestibular asymmetry and 20 controls; mean age = not reported):
Criterion validity:
Harvey et al. (1997) found that when both the Head Impulse Test and Head Shaking Nystagmus Test are abnormal, there is a high likelihood of caloric deficit.
Convergent Validity:
Peripheral Vestibular Dysfunction
Fujimoto et al., 1993 (n = 1364; mean age = 48.2): Peripheral vestibular dysfunction
Table 1: Fujimoto et al, 1993
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Correlation between ENG findings and HSN |
Sensitivity |
Specificity |
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Spontaneous nystagmus |
55.8% |
71.5% |
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Oculomotor exam (abnormal) |
35.6% |
68.7% |
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Positional nystagmus |
57.3% |
71.2% |
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Caloric reduction |
50.2% |
73.2% |
Table 2: Fujimoto et al, 1993
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R/L excitability |
> 20% |
> 40% |
> 60% |
> 80% |
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Sensitivity |
50.21 |
64.36 |
68.33 |
77.14 |
|
Specificity |
73.18 |
71.69 |
70.68 |
70.14 |
Asawavichiangianda, S., Fujimoto, M., et al. (1999). "Significance of head-shaking nystagmus in the evaluation of the dizzy patient." Acta Otolaryngol Suppl 540(540): 27-33. Find it on PubMed
Asawavichianginda, S., Fujimoto, M., et al. (1997). "Prevalence of head-shaking nystagmus in patients according to their diagnostic classification in a dizziness unit." The Journal of otolaryngology 26(1): 20-25.
Burgio, D. L., Blakley, B. W., et al. (1991). "An evaluation of the head-shaking nystagmus test." Otolaryngol Head Neck Surg 105(5): 708-713. Find it on PubMed
Fujimoto, M., Rutka, J., et al. (1993). "A study into the phenomenon of head-shaking nystagmus: its presence in a dizzy population." The Journal of otolaryngology 22(5): 376-379.
Goebel, J. A. and Garcia, P. (1992). "Prevalence of post-headshake nystagmus in patients with caloric deficits and vertigo." Otolaryngol Head Neck Surg 106(2): 121-127. Find it on PubMed
Hain, T. C. and Spindler, J. (1993). "Head-shaking nystagmus." The vestibulo-ocular reflex and vertigo. New York: Raven: 217-217.
Hall, S. and Laird, M. (1992). "Is head-shaking nystagmus a sign of vestibular dysfunction?" The Journal of otolaryngology 21(3): 209.
Harvey, S. A., Wood, D. J., et al. (1997). "Relationship of the head impulse test and head-shake nystagmus in reference to caloric testing." Am J Otol 18(2): 207-213. Find it on PubMed
Jacobson, G. P., Newman, C. W., et al. (1990). "Sensitivity and specificity of the head-shaking test for detecting vestibular system abnormalities." Ann Otol Rhinol Laryngol 99(7 Pt 1): 539-542. Find it on PubMed
Kamei, T. (1988). "Two types of head-shaking tests in vestibular examination." Acta Otolaryngol Suppl 458(S458): 108-112. Find it on PubMed
Takahashi, S., Fetter, M., et al. (1990). "The clinical significance of head-shaking nystagmus in the dizzy patient." Acta Otolaryngol 109(1-2): 8-14. Find it on PubMed
Tseng, H. Z. and Chao, W. Y. (1997). "Head-shaking nystagmus: a sensitive indicator of vestibular dysfunction." Clin Otolaryngol Allied Sci 22(6): 549-552. Find it on PubMed
Vicini, C., Casani, A., et al. (1989). "Assessment of head shaking test in neuro-otological practice." ORL J Otorhinolaryngol Relat Spec 51(1): 8-13. Find it on PubMed
Wei, D., Hain, T. C., et al. (1989). "Head-shaking nystagmus: associations with canal paresis and hearing loss." Acta Otolaryngol 108(5-6): 362-367. Find it on PubMed
We have reviewed more than 500 instruments for use with a number of diagnoses including stroke, spinal cord injury and traumatic brain injury among several others.