Subjective Vestibular Assessment

Original Editor - Jess Bell based on the course by Bernard Tonks
Top Contributors - Jess Bell and Kim Jackson

Introduction[edit | edit source]

As discussed here, there are a number of conditions that can cause dysfunction of the vestibular system. Examples of vestibular pathologies include:

  • Vestibular labyrinthitis or neuritis (also termed neuronitis)
  • Labyrinthine concussion (unilateral vestibular lesions (UVL) or bilateral vestibular lesions (BVL)) or post-concussion syndrome
  • Benign paroxysmal positional vertigo (BPPV)
  • Perilymphatic fistula
  • Primary endolymphatic hydrops (Meniere’s disease)
  • Secondary endolymphatic hydrops (traumatic, infections etc)
  • Utricular dysfunctions
  • Superior canal dehiscence syndrome (congenital, but trauma can also ‘activate’)
  • Central vestibulopathies (sensory integration dysfunctions)
  • Drug toxicity
  • Persistent postural-perceptual dizziness (PPPD)
  • Mal de Debarquement Syndrome (MdDS)

A detailed subjective and objective assessment is necessary when treating patients with vertigo or dizziness in order to determine the most effective treatment for each patient. This page will discuss the subjective evaluation in detail.

Subjective Evaluation[edit | edit source]

When taking a subjective history, the following questions should be asked:[1]

  • How long do the episodes of dizziness or vertigo last (i.e. seconds, minutes or hours)?
  • Does the patient have vertigo or more generalised dizziness and disequilibrium (or both)?
  • Has the patient had any medical investigations or been given a diagnosis?
  • Does the patient have a history of head trauma or other precipitating factors?
  • Does the patient experience symptoms with visual tasks or in complex, motion rich environments?

It is also important to consider the conditions or symptoms discussed below in the subjective interview.

Mal de Debarquement Syndrome (MdDS)[edit | edit source]

MdDS is a form of sensory integration dysfunction. If a patient complains of a rocking or swaying sensation (i.e. as if they are on a ship), MdDS should be considered in the differential diagnosis.[2]

The vestibular system must be able to adapt to continuous passive motion – for example while travelling at sea - and then re-adapt when back on land. In MdDS, this re-adaptation does not occur. The symptoms of rocking / swaying persist sometimes for months and occasionally for years.[3] Typically, MdDS patients feel better when they are in motion.[1][2]


Motion Sickness[edit | edit source]

Asking about motion sickness in the subjective assessment of vestibular patients is relevant because a history of motion sickness indicates that:[1]

  • A patient’s central nervous system may choose strategies to manage sensory conflict that are not adaptive
  • There is a sensory mismatch between vestibular and visual cues[1][5]


Oscillopsia[edit | edit source]

Oscillopsia is the subjective illusion of visual motion  - it is caused by a malfunction of the vestibulo-ocular reflex (VOR).[7] It can only occur when an individual’s eyes are open and it frequently presents with peripheral BVLs.[1]

Floating, Swimming, Spinning Inside the Head[edit | edit source]

These symptoms are frequently associated with anxiety, depression and somatoform disorders. The vestibular system does not tend to cause these types of sensations.[1]

Vertical Diplopia[edit | edit source]

Vertical diplopia is a type of double vision where the individual sees two images, which line up vertically:[1]

  • Symptoms disappear if either eye is closed
  • It is often caused by skew eye deviation and is due to an otolith dysfunction or otolith processing issue

Vertigo[edit | edit source]

Vertigo is defined as the illusion of movement of self or of the environment. It is an entirely subjective phenomenon. If vertigo is related to a dysfunction of the vestibular system, it will be due to a sudden imbalance of tonic neural output.[1]

Lightheadedness or Presyncope[edit | edit source]

These symptoms are related to orthostatic hypotension - they are not a vestibular symptom.[1]


Symptom Provocation[edit | edit source]

It is important in the subjective interview to determine the circumstances which provoke symptoms. For example, find out if symptoms:[1]

  • Are provoked by certain movements of the head and body, or in situations where there is visual-vestibular-somatosensory mismatch
  • Occur in busy, noisy and motion rich environments
  • Are related to specific visual tasks and activities

For a summary of the key symptoms of dizziness and their underlying mechanisms, please see Table 1.

Table 1. Symptoms of Dizziness
Symptoms Mechanisms
Disequilibrium - imbalance or unsteadiness while standing or walking Loss of vestibulospinal, proprioceptive, visual, motor function, joint pain or instability and psychological factors
Lightheadedness or presyncope Decreased blood flow to the brain
Sense of rocking or swaying as if on a ship (MdDS) The vestibular system adapts to continuous, passive motion and must re-adapt once the environment is stable
Motion sickness Visual-vestibular mismatch
Nausea and vomiting Stimulation of medulla
Oscillopsia - illusion of visual motion Spontaneous: acquired nystagmus

Head-induced: severe, bilateral loss of VOR

Floating, swimming, rocking, and spinning inside the head Anxiety, depression and somatoform disorders
Vertical diplopia Skew-eye deviation
Vertigo - rotation, linear movement, tilt Imbalance of neural activity to the vestibular cerebral cortex

Falls[edit | edit source]

Patients with UVLs do not tend to fall more than their age-matched peers. However, patients with BVLs are more at risk of falling:[1]

  • The risk of falling increases in those who have fallen more than twice in the past 6 months

Questions to ask include:[1]

  • Was the individual injured in the fall?
  • When and how did the fall occur?
  • Has the individual changed his / her lifestyle due to the fall?

Functional Status[edit | edit source]

Subjective Outcome Measurement[edit | edit source]

The Dizziness Handicap Inventory (DHI or DI) can be useful for both the subjective evaluation of vestibular patients and as an outcome measure. It enables the clinician to measure a patient’s perception of his / her disability[1] - i.e. the impact of the dizziness on his / her quality of life.[9] Items relate to functional, emotional and physical problems.[10]

A score of 16 to 34 indicates the patient perceives his/ her dizziness as mild. A score of 36 to 52 suggests moderate symptoms and a score of over 54 suggests a perception that the dizziness is severe.[11]

Psychosocial Status[edit | edit source]

Psychosocial status has to be considered as anxiety is known to have a disruptive influence on vestibular rehabilitation.[1][12]

The Positive and Negative Affective Scale (PANAS) can be used for vestibular patients. It is a screening tool that can be used to assess the presence of anxiety or depression, but it is important to note that it does not indicate the cause of symptoms.[1]

Cognitive Vestibular Interactions[edit | edit source]

Individuals with vestibular dysfunction might also present with cognitive dysfunction,[13] including decreased memory, compromised concentration and impaired abilities when multitasking.[1]

  • There are projections of pathways from the vestibular system to the cortex[14]
  • A recent study by Brandt and colleagues suggested that “moving towards a concept of higher vestibular disorders” would be helpful [14]
  • This interaction between cognitive and vestibular dysfunction probably represents problems with sensory integration (visual, vestibular)[14]

Summary[edit | edit source]

  • A number of conditions can cause dizziness and vertigo symptoms
  • It is essential to determine the nature and perceived severity of the patient's symptoms before conducting a thorough objective assessment
  • The objective assessment of vestibular patients is discussed here

References[edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 Tonks B. Vestibular Assessment Course. Plus , 2021.
  2. 2.0 2.1 Saha KC, Fife TD. Mal de débarquement syndrome: Review and proposed diagnostic criteria. Neurol Clin Pract. 2015;5(3):209-15.
  3. Cha YH, Brodsky J, Ishiyama G, Sabatti C, Baloh RW. Clinical features and associated syndromes of mal de debarquement. J Neurol. 2008;255(7):1038-44.
  4. Whiteboard Medical Journal [WMJ]. Mal de debarquement syndrome (Motion sickness WITHOUT the motion). Available from: [last accessed 5/7/2021]
  5. Koch A, Cascorbi I, Westhofen M, Dafotakis M, Klapa S, Kuhtz-Buschbeck JP. The Neurophysiology and Treatment of Motion Sickness. Dtsch Arztebl Int. 2018;115(41):687-96.
  6. TED-Ed. The mystery of motion sickness - Rose Eveleth. Available from: [last accessed 5/7/2021]
  7. Hain TC, Cherchi M, Yacovino DA. Bilateral vestibular weakness. Front Neurol. 2018;9:344.
  8. PhysioPathoPharmaco. Orthostatic Hypotension (Described Concisely). Available from: [last accessed 5/7/2021]
  9. Tamber AL, Wilhelmsen KT, Strand LI. Measurement properties of the Dizziness Handicap Inventory by cross-sectional and longitudinal designs. Health Qual Life Outcomes. 2009;7:101.
  10. Mutlu B, Serbetcioglu B. Discussion of the dizziness handicap inventory. J Vestib Res. 2013;23(6):271-7.
  11. Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990;116:424-7.
  12. Saman Y, Bamiou DE, Gleeson M, Dutia MB. Interactions between stress and vestibular compensation - a review. Front Neurol. 2012;3:116.
  13. Rizk HG, Sharon JD, Lee JA, Thomas C, Nguyen SA, Meyer TA. Cross-sectional analysis of cognitive dysfunction in patients with vestibular disorders. Ear Hear. 2020;41(4):1020-7.
  14. 14.0 14.1 14.2 Brandt T, Strupp M, Dieterich M. Towards a concept of disorders of "higher vestibular function". Front Integr Neurosci. 2014;8:47.