Hearing, Balance and Communication

ISSN: 2169-5717 (Print) 2169-5725 (Online) Journal homepage: http://www.tandfonline.com/loi/ihbc20

Clinical application of the head impulse test of

semicircular canal function

I. S. Curthoys & L. Manzari

To cite this article: I. S. Curthoys & L. Manzari (2017): Clinical application of the head
impulse test of semicircular canal function, Hearing, Balance and Communication, DOI:
10.1080/21695717.2017.1353774

To link to this article: http://dx.doi.org/10.1080/21695717.2017.1353774

© 2017 The Author(s). Published by Informa

UK Limited, trading as Taylor & Francis
Group.

Published online: 18 Jul 2017.

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HEARING, BALANCE AND COMMUNICATION, 2017
https://doi.org/10.1080/21695717.2017.1353774

REVIEW ARTICLE

Clinical application of the head impulse test of semicircular canal function

I. S. Curthoysa and L. Manzarib
a
Vestibular Research Laboratory, School of Psychology, University of Sydney, Sydney, Australia; bMSA ENT Academy Center,
Cassino, Italy

ABSTRACT KEYWORDS
Objective: To review the theory, the validity and the clinical application and the new develop- vHIT; vestibular; semicircular
ments of the video head impulse test (vHIT) of semicircular canal function. vHIT has now super- canal; VOR
seded the caloric test as the first-line clinical test for vestibular patients.
Outcomes: This review examines the origin and rationale for vHIT: how it is carried out; pitfalls
in testing; the validation of the test; the interpretation of overt and covert compensatory sac-
cades in patients with vestibular loss; how the area VOR gain is calculated.
Results: The advantages of the test are considered: it is so innocuous that it can be given to
patients even during acute vertigo attacks, and given repeatedly at short intervals; it is very suc-
cessful for testing young children; it tests all six semicircular canals, and, unlike the caloric test,
provides measures of the absolute level of canal function and so is valuable for monitoring the
effect of ototoxic antibiotics as well as identifying bilateral vestibular loss. Patients with
Meniere’s disease have normal canal function, although their caloric results generally indicate
otherwise, with hydrops being the possible cause for that divergence. vHIT has shown the new
vestibular syndrome of bilateral loss of vertical canal function and it is now being used for iden-
tifying the likely cause of vertigo of patients arriving at a hospital Emergency Room – normal
semicircular canal function in such patients indicating increased probability of a stroke. The the-
ory and application of the new, but already widely used, variant called the suppression head
impulse test (SHIMPs) is explained. SHIMPs is even simpler and more intuitive than the standard
vHIT test and probably even better for testing children.
Conclusion: This review provides the theoretical foundations for the practical application of the
clinical vHIT test which has revolutionized the clinical testing of semicircular canal function.

Abbreviations: VOR: vestibulo-ocular reflex; HIT: head impulse test; vHIT: video head impulse
test – the technology; HIMP: the head impulse test – the procedure; SHIMP: the suppression
head impulse test – the procedure; LARP: the plane of the left anterior right posterior canals;
RALP: the plane of the right anterior, left posterior canals

The head impulse test – history
The semicircular canals are stimulated by angular
head rotation and drive smooth eye movements to
compensate for that head rotation. For many years
the smooth eye movement responses to low frequency
sinusoidal horizontal head rotations were used to
assess the functional status of the semicircular canals
[1,2]. However, many other oculomotor control sys-
tems can also generate smooth eye movements –
smooth pursuit, cervico-ocular reflex, optokinetic
reflex – so inferring semicircular canal function spe-
cifically from an eye movement response is unjusti-
fied. In order to justify that inference it is necessary
to show that the other control systems do not contrib-
ute to the generation of the eye movement response
for that particular stimulus. But how is it possible to
exclude these other oculomotor control systems and
identify the specific, unique vestibular contribution?
Halmagyi and Curthoys answered this question by
testing a very rare patient who had absolutely zero ves-
tibular function following bilateral surgical removal of
both VIII nerves to treat bilateral neurofibromatosis
[3]. He had recovered very well after these surgeries
and his other sensory inputs – for example vision, cer-
vico-ocular reflex – were unaffected by the surgeries.
Since he had zero vestibular input it was reasoned that
testing this patient would indicate what was, and what

CONTACT Ian S. Curthoys ianc@psych.usyd.edu.au Vestibular Research Laboratory, School of Psychology, A 18, University of Sydney, Sydney,
NSW 2006, Australia
ß 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/Licenses/by-
nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed,
or built upon in any way.
2 I. S. CURTHOYS AND L. MANZARI

was not, a valid, specific, vestibular-dependent eye
movement response. And so it was [3–5]. Firstly, this
avestibular patient could generate smooth compensa-
tory eye movements to passive sinusoidal horizontal
head rotations at 0.2 Hz, which showed that low fre-
quency sinusoidal horizontal rotation is not a specific,
valid vestibular test. Such a stimulus is highly predict-
able and we reasoned that the patient may have been
using predictive pursuit to generate the response.
Similarly, this avestibular patient could generate
smooth compensatory eye movements to active hori-
zontal head turns, so the eye movement response to
active head movements is also not a valid, specific test
of semicircular canal function.
On the other hand, this avestibular patient did not
generate smooth compensatory eye movement during
the first 100–150 ms of a brief, abrupt, passive, unpre-
dictable horizontal head turn through 15 –20 (which
we now call a head impulse) (Figure 1). The patient
was instructed to keep looking at a dot on the wall –
an earth-fixed LED target 1 m away from him in an
otherwise dark room – and his head was turned by
the clinician through a small angle (10 –15 ) to the
right or left, in an abrupt, unpredictable fashion. The
fixation LED was turned off just before the impulse
and the patient was asked to keep staring where he
imagined the LED to be. The angular accelerations
during the head impulse stimulus are of the order of
1000 –4000 /s/s, similar to the angular accelerations
which occur during normal everyday activities – driv-
ing, running, playing sport [6]. These natural values
of angular accelerations are about 100 times larger
than the accelerations used in the clinical vestibular
test using low frequency sinusoidal rotations. The
essential features of the head impulse are that it is
passive, it has a sharp onset, is brief (about
100–150 ms) and the direction is unpredictable. Since
this patient with no vestibular input, but with all
other oculomotor control systems intact, failed the
test, the head impulse was clearly a valid specific test
of semicircular canal function.
These responses of the avestibular patient also show
that other oculomotor control systems do not generate
smooth compensatory eye movements during this ini-
tial time window. Recordings of this patient’s eye
movements with the ‘gold standard’ system – scleral
search coils – showed that during the early part of the
impulse there was no compensatory eye movement at
all – his eyes remained fixed in his head as the head
was turned (Figure 1) [3]. After about 120 ms there
was a small slow compensatory eye movement which
we attribute to cervical sensory input driving the eyes
by the cervico-ocular response which is enhanced in
patients with bilateral vestibular loss [7].
Since his eyes moved with his head during the
head impulse, they were taken off the fixation target,

Healthy Subject Bilateral vestibular loss

HEAD & EYE VELOCITY HEAD & EYE VELOCITY

. .
E E
. .
H H
100 °/s 100 °/s

0 °/s 0 °/s

TIME 100 msec TIME 100 msec

Figure 1. Validation of the head impulse test as a test of vestibular function. (A) The superimposed time series of head velocity
and (inverted) eye velocity for a healthy subject during an abrupt, passive, unpredictable head turn through a small angle. The
smooth compensatory eye velocity closely matches and so compensates for head velocity. (B) Comparable time series plots for a
patient with absent vestibular function bilaterally after bilateral surgical removal of both vestibular nerves for treatment of NF2.
The patient was alert and motivated and understood the instructions, but did not generate any compensatory eye velocity
response during the first 120 ms of the stimulus. A small late slow eye velocity occurs which may be due to cervico-ocular reflex.
Reproduced with permission from Curthoys and Halmagyi [52]. Copyright# 1992 Karger Publishers, Basel, Switzerland.
 HEARING, BALANCE AND COMMUNICATION 3

and so at the end of the impulse his gaze was no lon-
ger on the earth-fixed target and he had to make a
compensatory saccade (in the direction opposite to
head turn) to return his gaze to the target as
instructed (not illustrated here). These compensatory
saccades after the head impulse came to be called
overt saccades since they are easily detectable by a
clinician carrying out the head impulse test. These
saccades became the clinical sign of canal paresis [4]
since patients with unilateral vestibular loss made
these same overt saccades after head turns to their
affected side. So a patient with a left affected ear

Figure 2. Superimposed time series of head velocity and (inverted) eye velocity during horizontal head impulses for a healthy sub-
ject (A, B) and a patient with a unilateral vestibular loss (C, D). For the healthy subject eye velocity matches head velocity for both
directions of rotation. For the patient, eye velocity is much lower than head velocity for head turns to the affected side and there
are many compensatory saccades – either after the impulse (overt saccades) or during the impulse (covert saccades). The eye vel-
ocity for head turns to the patient’s healthy side is reduced, because the contribution from the opposite side is absent.

Figure 3. To calculate VOR gain, the area under the eye velocity record (light grey/orange in the web version) is divided by the
area under the head velocity record (dark grey/blue in the web version), and the figure shows how the ratio of those areas is
about 1.0 in healthy subjects (A) but unilateral loss decreases that ratio (B). This area VOR gain is less affected by minor deviations
in eye velocity which can affect VOR gain calculated from just eye velocity records [18].
4 I. S. CURTHOYS AND L. MANZARI
made corrective saccades after a head impulse to the
left (Figure 2).
During the head turn it is not possible for the test-
ing clinician to see the smooth compensatory eye
movement response. What is easy to detect is the
overt corrective saccade at the end of the head
impulse. The instructions to the patient are to main-
tain fixation on the dot on the wall (the so-called
earth-fixed fixation target), about 1 m in front of the
patient, or alternatively they are instructed to keep
looking at the clinician’s nose, directly in front of the
patient. Healthy subjects make smooth compensatory
eye movements during the unpredictable head
impulse stimulus so their gaze remains on the target.
When Halmagyi and Curthoys and colleagues
started to make regular measurements of the response
of vestibular patients to head impulses using scleral
search coil recording of eye movements with high
speed, high resolution data acquisition it was found
that some patients with reduced semicircular canal
function managed to make the corrective saccade dur-
ing the head turn [8]. These are not detectable by the
testing clinician and so we called them covert sac-
cades, since patients with vestibular loss making such
covert saccades would thus be classified as having
normal function. Their presence made it imperative
that there be a system for measuring the eye move-
ment at high speed actually during the head turn.
Scleral search coil testing is not clinically feasible so
we needed to have a fast eye movement recording sys-
tem which gave resolution comparable to search coils
which could detect these covert saccades and was feas-
ible for clinical use. This was achieved by Hamish
MacDougall who invented tight fitting goggles with
minimal slippage and a very clever way of mounting a
small, light-weight, high-speed, video camera in the
goggles to provide a clear sharp image of the eye dur-
ing the head turn [9]. This technology is the video
head impulse technology (vHIT). To date the vHIT
system has been used in the standard protocol using
head impulses to test semicircular canal function.
More recently the vHIT technology is being used to
test smooth pursuit and visual vestibular interaction –
very different test protocols to those used in the head
impulse test. For clarity we now refer to the video
technology as vHIT and the test protocol as the Head
Impulse test of semicircular canals as HIMPs (or
SHIMPs – explained below).
The validation of vHIT
To validate the new technology of vHIT, we published
the comparison of the recordings of the eye
movements by vHIT to exactly simultaneous scleral
search coil recordings of the same eye during head
impulse testing (HIMPs) in Neurology in 2009 [9].
The comparison showed that the video technology
gave results comparable to scleral search coils. The
company Otometrics developed the video technology
and markets the system as Impulse. Many other com-
panies have copied this system since, but so far the
Otometrics system is still the only system validated by
exactly simultaneous measures of the same eye during
head impulses.
We conclude that the head impulse test (HIMPs) –
the eye movement to a passive, brief, unpredictable,
high (natural) head acceleration stimulus – is a spe-
cific test of semicircular canal function. Failure to
generate an oculomotor response to this stimulus
means that the patient probably has reduced or absent
semicircular function on the side to which the head is
turned. The word ‘probably’ is used since deficits
other than peripheral vestibular deficits can also result
in a reduced or absent response on the head impulse
test and these must be excluded – for example eye
muscle absence or eye muscle weakness or central def-
icits. In the usual vestibular clinical setting these are
not common. There is also a cognitive component
since the person must understand the instructions
and cooperate.
Active head impulses where the patient turns their
own head do not detect vestibular loss [10]. This is
not surprising since the neural mechanisms for gener-
ating active head movements can be brought into play
to generate the eye movement response as well as the
head movement. So, active head impulses are not a
valid, specific indicator of semicircular canal function,
as in fact we had already shown with the avestibular
patient [3].
Application of the head impulse test
The head impulse test has significant advantages.
Because vision is not important, the test can be con-
ducted in a fully lit room, and in fact it should be
conducted in such a room as we explain in Appendix
I. It allows testing of vestibular function even in bed-
bound patients without the necessity for specialized
equipment, such as a rotating chair, or the need for
special testing conditions – such as total darkness. It
is very quick, objective, is readily accepted by patients,
it can be used repeatedly in a short time and it can be
conducted even during attacks of vertigo.
Head turns are the natural stimulus for the semi-
circular canals which are stimulated naturally by
angular head movements. The thermal stimulus which

has been used for the last century in the caloric test is
a completely unnatural way of stimulating the semi-
circular canals, and precisely how caloric stimulation
works is still not fully understood [11,12]. The head
impulse test uses natural values of the natural stimu-
lus which the semicircular canals have evolved to
detect.
For safety reasons we do not use a mechanical system
to deliver the head impulse stimulus exactly each time.
The accelerations are so large that even a minor fault
would probably cause major injury. Instead vestibular
stimuli are presented which are not well controlled – a
head turn delivered by an operator can vary from one
trial to the next – but in vHIT both the head movement
stimulus and the eye movement response are measured
exactly each time, and the analysis relates each response
to the stimulus which caused that response.
Measuring vestibular function – VOR gain
We could use any of a range of measures of vestibular
performance. In vestibular research it has been cus-
tomary to use VOR gain to assess the functional state
of the canals. This was borrowed from engineering
and it is defined as the ratio of eye velocity to head
velocity. So, a VOR gain of around 1.0 is regarded as
normal because the eye velocity exactly compensates
for head velocity. VOR gains significantly less than
1.0 show reduced semicircular canal function. VOR
gain is not a fixed value – it varies from trial to trial,
and even within the one trial from moment to
moment [13,14]. Textbooks give the impression that
the VOR gain should be exactly 1.0. In fact this is
very rarely true. In our experience perfectly healthy
people who have no symptoms of visual blur or oscil-
lopsia can have gains much smaller than 1.0 – for
example 0.85 or less – or gains much higher than 1.0,
up to 1.2. The literature on the VOR shows that
many factors influence the gain of the VOR such as
viewing distance, spectacle prescription [15].
There are problems with using the ratio of eye vel-
ocity to head velocity as the measure of performance
– at what value of head velocity should this ratio be
measured? Most important for video measures – any
slippage of the goggles will result in a perfect apparent
eye movement in response to the apparent head
movement. Slippage occurs with every video system.
It should be minimized by tight fitting goggles but
since the goggles are not fixed to the skull, there is
always some slippage. Head mounted goggle systems
which claim this slippage does not occur simply have
not measured the slippage carefully enough. Given
HEARING, BALANCE AND COMMUNICATION 5
that the whole eye movement is just a few degrees, it
is clear that even small slippage is important in meas-
uring canal performance.
We have conducted many investigations and simu-
lations to assess the impact of slippage on measures of
performance and to minimize this slippage artifact
which bedevils the simple eye velocity/head velocity
calculation [16,17]. Firstly, saccades are removed from
the eye velocity curve using an eye acceleration tech-
nique to detect the saccades. The VOR performance
measure which was least affected by slippage is the
area under the whole eye velocity curve of the head
impulse compared to the area under the whole head
velocity curve of the head impulse (Figure 3). Our
simulations showed that the area VOR gain minimizes
the impact of artifacts and variations at any particular
moment (see also [18]).
Why is it necessary to test function using high
velocity head turns (>150 /s)?
Rotational testing of semicircular canal function has a
major drawback. The one head movement causes
complementary stimulation of canals on both sides of
the head, and physiological studies show that the
neural input from both ears contributes to the
response at low head velocities [19,20]. In patients
with unilateral loss the contribution from the healthy
ear can be ruled out by using high acceleration head
impulses which silence the input from the opposite
side. If low acceleration (low frequency, low velocity)
head impulses are used, the remaining healthy ear can
quite effectively drive the eye movement response for
head turns to the affected ear, so that the affected ear
appears to have a normal VOR gain. That is why high
acceleration stimuli (peak head velocity above 150 /s)
are mandatory.
Advantages
Recent studies [16] showed that vHIT can measure
the function of all six canals in contrast to the tests of
just two canals using the caloric (Figure 4). More
importantly HIMPs testing gives absolute values of
semicircular canal function which are not credible in
caloric testing because so many irrelevant factors (like
skull size, temporal bone blood supply, etc.) affect the
thermal stimulus reaching the inner ear and so affect
the eye velocity response to the caloric stimulus. The
main measure with the caloric test is the asymmetry
of slow phase eye velocity between comparable stimu-
lation of the two ears. But testing with HIMPs has
6 I. S. CURTHOYS AND L. MANZARI

Figure 4. The HIMPs protocol using vHIT can be used to test all six canals, extending the principles explained above for just hori-
zontal impulses. We have used this hexagonal display to show the responses of the vertical as well as the horizontal canals. The
terms: RALP refers to the right anterior-left posterior canal pair and LARP refers to the left anterior-right posterior canal pair. Slow
phase eye velocities are shown in dark grey (blue in the web version) and saccades in medium grey (red in the web version). The
superimposed time series records (and associated VOR gain values) show that this patient has a unilateral loss affecting the hori-
zontal, anterior and posterior canals on the right side, whereas all the canals on the left side have reasonable gains – but with
somewhat reduced gains compared to normal values. Reproduced from MacDougall, McGarvie, Halmagyi, Curthoys and Weber
(2013), “Application of the Video Head Impulse Test to Detect Vertical Semicircular Canal Dysfunction”, Otology & Neurotology 34
(6): 974-9, with permission of Wolters Kluwer Health, Inc. http://journals.lww.com/otology-neurotology. Promotional and commer-
cial use of the material in print, digital or mobile device format is prohibited without permission from the publisher Wolters
Kluwer. Please contact healthpermissions@wolterskluwer.com for further information.

shown that there can be decline in absolute VOR
gain, equal in both canals of a pair. For example,
complete bilateral canal loss or bilateral anterior or
posterior or horizontal canal loss [21,22]. These new
discoveries [23] have dramatically increased our
understanding of semicircular canal function, and
they help to explain some of the otherwise very puz-
zling patient complaints of vestibular symptoms des-
pite caloric testing showing normal symmetrical
horizontal canal function.
The HIMPs test is especially valuable in testing the
semicircular canal function of young children [24–26].
In particular the new variant of HIMPs, the SHIMPs
paradigm (explained below), is a very easy, intuitive
task which can be easily understood even by very young
children.
These measures of absolute level of semicircular
canal function have been particularly valuable for
assessing the semicircular canal function of patients
receiving the ototoxic antibiotic gentamicin [27–29],
which selectively attacks the type I receptors at the
crest of the crista [30,31] which appear to have a
major role in the initiation of the head impulse
response. Gentamicin may be given to treat infection
without the physician realizing that gentamicin kills
vestibular hair cell receptors, with very little effect on
auditory receptors and the ototoxicity only becoming
apparent when the patient tries to walk. A detailed
history of patients with bilateral vestibular loss may
reveal an earlier gentamicin treatment [32].
One important use of the HIMPs is to test patients
arriving at the hospital Emergency Room in the midst

Figure 5. Saccadic clustering. Time series of vHIT for horizontal impulses towards the affected side for two patients post-vestibular
schwannoma removal, showing examples of clustered saccade pattern (A), and disorganized saccade pattern (B). The clustered sac-
cades (A) here appear in three main time intervals, one towards the end of the impulse, and two more clusters after the impulse.
This pattern is characteristic of a patient who is compensating for the loss of function on the affected side. The disorganized sac-
cades do not show the same clustering, but are distributed more uniformly. The gain of the VOR and the number of impulses are
shown on each plot.
of an acute attack of vertigo. The results of HIMPs test-
ing using vHIT help to discriminate whether the ver-
tigo is due to a stroke, or to peripheral vestibular
neuritis. If vHIT shows the patient has normal semicir-
cular canal function, but complains of vertigo, then it
is more likely the person has had a central stroke. That
likelihood increases if other vestibulo-ocular signs
(such as skew deviation) are also considered [33].
The simplicity of HIMPs and its relatively innocu-
ous character for patients means that it can be used
even during vertigo attacks. So it has been used
to show in patients with Meniere’s disease how semi-
circular canal function fluctuates during and around
the time of the attack of vertigo [34,35]. It has also
been used to help discriminate between the vertigo
due to Meniere’s disease as opposed to vertigo due to
peripheral vestibular neuritis [36], as well as docu-
menting the full recovery after peripheral vestibular
neuritis [37].
Saccade clustering
Recently there has been growing interest in the tem-
poral spacing (clustering) of the compensatory cor-
rective saccades in HIMPs results for unilateral
patients, and how that clustering changes as recovery
from vestibular deficit progresses [38]. The overt and
covert saccades may occur in tight clusters during or
just after the head movement (Figure 5(A)). This pat-
tern appears to be associated with improved outcomes
of that patient’s recovery. In other patients the sac-
cades may be temporally dispersed (Figure 5(B)). In
some patients that dispersion decreases over time,
possibly related to the progression of vestibular recov-
ery. It may be that patients who successfully
HEARING, BALANCE AND COMMUNICATION 7
compensate after vestibular loss use covert saccades to
obscure the retinal slip that must occur because of
their inadequate VOR [39]. These matters are still
under investigation.
The HIMPs test is now being used as an indicator of
the appropriate dosage of intratympanic gentamicin
for the therapeutic treatment of patients with severe
Meniere’s disease. After a single intratympanic injec-
tion the patients may have only lost a small amount of
semicircular canal function as shown by HIMPs, but
that may be enough to eliminate their vertigo whilst
retaining useful semicircular canal function [40].
Many clinicians now recommend that vHIT and the
HIMPs protocol should be the first test given to
patients arriving at a vestibular clinic [41,42] – replac-
ing the caloric as the initial clinical test. It is very fast, it
is relatively innocuous, and is very well tolerated by
patients, even patients in the midst of an acute attack of
vertigo [36]. It allows the assessment of their absolute
level of vestibular function of all canals [43], not just
the symmetry of function of the horizontal canals as in
the caloric test. Clinicians and technicians prefer giving
this test to giving the caloric since it quickly provides
accurate data about the absolute level of semicircular
canal function without making patients ill.
The head impulse test versus caloric
When the head impulse test was first published there
was a rush of papers comparing its results to the
results of the caloric. But, calorics and head impulses
are just two totally different ways of testing the semi-
circular canals. The mistake has been to assert that
the caloric test is the ‘gold standard’ indicator of the
level of semicircular canal function. That is not
8 I. S. CURTHOYS AND L. MANZARI

Figure 6. The two test protocols: HIMPs and SHIMPs. (A) In the usual protocol for head impulse testing (HIMPs) the person is
instructed to maintain fixation on an earth-fixed target during a small unpredictable passive head turn. Because of the VOR
healthy subjects do not make any large saccades. (B) In the SHIMPs protocol the head turn is identical but the instructions are dif-
ferent – the person is instructed to maintain fixation on a head-fixed target (a spot from a head-mounted laser projected onto
the wall in front of the subject). Healthy subjects make large saccades at the end of the impulse (see text for explanation).
Reproduced with permission from Halmagyi, Chen, MacDougall, Weber, McGarvie and Curthoys (2017), "The Video Head Impulse
Test", Frontiers in Neurology 8:258.

correct. The responses to caloric stimulation are so
variable between subjects that the caloric cannot give
acceptable information about the absolute level of
horizontal canal function. vHIT does gives such infor-
mation about the absolute level of function [44] of all
canals [43]. The comparisons between the two tests
showed that patients with Meniere’s disease may have
a greatly reduced or absent semicircular canal func-
tion shown by the caloric, yet these same patients
have a normal response to head impulse stimuli
[11,12] (and also to other rotational stimuli [45,46]).
The patients clearly still have good semicircular canal
function, despite their very poor performance on the
caloric. Far from having reduced or absent canal func-
tion as indicated by the caloric, these patients generate
normal VOR during head movements.
McGarvie et al. suggested that this dissociation
between the results of the two tests may come about
because of the increased fluid volume of the labyrinth
due to the hydrops of Meniere’s disease affecting the
thermal transfer in the caloric but not affecting the
canal response to angular acceleration stimulation. The
dissociation between the results of these two tests has
been suggested to be an index of Meniere’s disease [47].
Sensitivity and specificity of HIMPs
There is only one group in whom we know the real
level of vestibular function and thus can be used as
the reference group to assess sensitivity and specificity
of HIMPs testing, and that is patients who have com-
plete absence of semicircular canal function after sur-
gical section of the vestibular nerve. By definition the
level of vestibular function in that ear is zero. How
well does the HIMPs testing paradigm identify these
patients against normals? In a previous study of 37
such patients versus 37 normals, we found that for
the HIMPs test: the sensitivity was 1.0, specificity was
1.0 and so the probability of correct detection was 1.0.
Assessing sensitivity and specificity of vHIT against
the caloric is simply confirming the obvious fact that
the two tests are different – it does not establish the
true sensitivity or specificity of either test for detect-
ing the level of semicircular canal function.
SHIMP
A recent variant of the HIMPs protocol (called
SHIMPs) uses the vHIT technology to measure the eye
and head velocity, during the same small abrupt,
unpredictable head impulses as used in the HIMPs
protocol [48]. There is one major difference – the
instructions. In the usual HIMPs protocol the person is
instructed to fixate a target spot on the wall at a dis-
tance of a meter – an earth fixed target. However, in
this new SHIMPS protocol the person is required to
fixate a head-fixed target – a laser spot which moves
with the head. The head-fixed spot comes from a small
 HEARING, BALANCE AND COMMUNICATION 9

Figure 7. Superimposed time series of head (light grey/green in the web version) and eye (dark grey/blue in the web version) vel-
ocity records for a healthy subject during HIMPs trials (A) and SHIMPs trials (B). In HIMPs trials eye velocity matches head velocity
and only a few random saccades (medium grey; red in the web version) occur < AQ/>. In SHIMPs trials, for the same healthy con-
trol subject eye velocity matches head velocity during the head impulse, but at the end of the impulse there are very large anti-
compensatory saccades, to take the eyes back to the head fixed target. There is a slightly lower VOR gain during SHIMP trials
compared to HIMP trials. Reproduced from MacDougall, McGarvie, Halmagyi, Rogers, Manzari, Burgess, Curthoys and Weber (2016),
“A new saccadic indicator of peripheral vestibular function based on the video head impulse test”, Neurology 87(4):410–8, with
permission of Wolters Kluwer Health, Inc. http://www.neurology.org/Promotional and commercial use of the material in print,
digital or mobile device format is prohibited without permission from the publisher Wolters Kluwer. Please contact healthpermis-
sions@wolterskluwer.com for further information.

laser on the goggles projecting a spot on the wall. This
fixation spot moves with the head (Figure 6). So, the
patient has to keep looking at the spot. It is an even
simpler, more intuitive task than in HIMPs – the
instructions are: ‘just keep looking at the spot’ as
the head is turned passively and unpredictably. But the
outcome is the exact inverse of the standard HIMPs
paradigm – now the healthy subject makes a large sac-
cade at the end of the impulse (which we call a
SHIMPs saccade) (Figure 7), and the patient with total
vestibular loss does not make a saccade (Figure 8).
Why? During this brief passive unpredictable head
turn in both the HIMPs and the new SHIMPs para-
digm, the semicircular canal stimulation occurs and so
generates compensatory eye movements (the VOR).
In the HIMPs paradigm the VOR acts to keep gaze on
the earth fixed target. But in the SHIMPs paradigm the
VOR acts to drive the eyes off the target. Suppression
of the VOR occurs in healthy subjects, but VOR
suppression in this passive, high acceleration paradigm
takes around 80 ms from the onset of the head turn
[49], and during that whole time the healthy person’s
VOR acts to drive the eyes off the target.
For example: A healthy subject makes a SHIMPs
saccade because during the head turn to the left, ini-
tially the VOR drives the eyes opposite to the direction
of head turn, to the right. So at the end of the head
impulse, the head (and target) are pointed to the left,
while the subject’s gaze is directed to the right. So to
regain the target as instructed, the healthy subject must
make a large saccade from right to left (Figure 7). This
is the SHIMPs saccade – an anti-compensatory saccade
at the end of the head impulse – and it is a sign of a
healthy VOR. We called the whole paradigm SHIMPs
(for suppression head impulses) because we anticipated
(incorrectly) that the VOR would be suppressed during
the head impulse. A patient with complete vestibular
loss does not make a corrective saccade because he has
10 I. S. CURTHOYS AND L. MANZARI

Figure 8. Comparable superimposed time series of head and eye velocity records for a patient with bilateral vestibular loss during
HIMPs trials (A) and SHIMPs trials (B). The results for a typical patient with complete BVL showed a reversed saccadic pattern dur-
ing HIMP and SHIMP protocols compared to a healthy control. (A) During HIMP trials, the patient with BVL elicits mostly overt
positive catch-up saccades after the head impulse. (B) During SHIMP trials the same patient with BVL shows only very few sac-
cades after the end of the head impulse back to the head-fixed target. In the SHIMPs protocol it is the patient with vestibular loss
who has no saccades, whereas healthy subjects show large saccades – exactly the reverse of the saccadic pattern with the HIMPs
protocol. Reproduced from MacDougall, McGarvie, Halmagyi, Rogers, Manzari, Burgess, Curthoys and Weber (2016), “A new sac-
cadic indicator of peripheral vestibular function based on the video head impulse test”, Neurology 87(4): 410–8, with permission
of Wolters Kluwer Health, Inc. http://www.neurology.org/Promotional and commercial use of the material in print, digital or
mobile device format is prohibited without permission from the publisher Wolters Kluwer. Please contact healthpermissions@wol-
terskluwer.com for further information.

no VOR to drive his eyes off the target, so at the end
of the SHIMPs impulse he is looking at the target
(Figure 8). In fact the size of the SHIMPS saccade is
related to VOR gain [50] (Figure 9).
One issue is that patients may try to anticipate
which direction the next head turn will be and so
make an anticipatory saccade, which interferes with
the VOR measure. This can be avoided if the operator
gives the occasional vertical head impulse – turning
the head up or down rather than left or right. We
have found that by interleaving such vertical turns
patients have trouble guessing which way the next
head turn will be, and so anticipatory saccades are
reduced.
The SHIMPs protocol is the perfect complement
to the HIMPs protocol, and both use the
vHIT technology. The SHIMPs paradigm yields two
measures of vestibular function: VOR gain, and the
size of the corrective saccade which has been shown
to be related to VOR gain [50]. Care must be taken in
the interpretation of the SHIMPs results because fac-
tors other than vestibular function influence the size
of the corrective saccade – such as the peak head vel-
ocity and the magnitude of the overshoot (rebound of
the head movement) at the end of the head impulse.
Nevertheless the SHIMPs saccade is a very useful clin-
ical indicator. In bedside testing, a large SHIMP sac-
cade indicates normal semicircular canal function.
The test paradigm is far simpler to explain to patients
– just look at the dot. Our measures with search coils
show this SHIMPs protocol is a valid indicator of ves-
tibular loss and it exactly complements the HIMPs
protocol [48].
Conclusion
The two testing protocols, HIMPs and SHIMPs, are
complementary ways of testing semicircular canal
function, and the vHIT technology provides the object-
ive records of head velocity and eye velocity for deter-
mining the level of vestibular function. The HIMPs
and now the new SHIMPs tests are being recognized as
the effective way of testing semicircular canal function.
Hamish MacDougall’s invention of vHIT has revolu-
tionized semicircular canal testing, and when its results
are combined with the tests of otolith function – the
new ocular and cervical vestibular evoked myogenic
 HEARING, BALANCE AND COMMUNICATION 11

Figure 9. HIMP and SHIMP data for the horizontal canal tests for a patient with unilateral vestibular loss in the left ear. In the
standard HIMP protocol, the gain of the VOR is greatly decreased for rotations towards the affected side (A), with large compensa-
tory corrective saccades. For rotations to the healthy side (B), the gain is slightly lower than normal, with a few very small correct-
ive saccades. In the SHIMP protocol, the gains towards the affected (C) and healthy sides (D) are similar to the corresponding
gains for the HIMP protocol, but the saccade pattern is reversed. Towards the healthy side (D) there are very large anticompensa-
tory SHIMPs saccades at the end of the impulse. Towards the affected side (C) are a few late small saccades. The gain of the VOR
is not zero so the corrective saccades are very small compared to the saccade amplitude for impulses to the healthy side (D).

potential tests – it is possible to measure the function ORCID

of all vestibular sense organs [51]. I. S. Curthoys http://orcid.org/0000-0002-9416-5038

Acknowledgements
We are grateful for the help of Ann Burgess in preparing
this paper and to Michael Halmagyi, Hamish
MacDougall, Leigh McGarvie and Konrad Weber. Much
of the work reported here has been supported by the
Garnett Passe and Rodney Williams Memorial Foundation
and the National Health and Medical Research
Foundation of Australia.
Disclosure statement
IC is an unpaid consultant to GN Otometrics, Taastrup,
Denmark, but has received support from GN Otometrics
for travel and attendance at conferences and workshops.
LM reports no conflicts of interest.
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HEARING, BALANCE AND COMMUNICATION 13
Appendix I. Doing the test
Testing should be conducted in a well-lit room in order to
keep the pupil small. Visual stimuli do not affect the test.
The patient is seated and the height of their head should be
at a comfortable level for the operator. Steps:
1. Goggle slippage. The goggles must be put on tightly
because any goggle slippage leads to errors. Ensure the
patient’s eyelids do not obstruct the pupil – tape up if
necessary.
2. Calibration. It essential that the calibration is as accur-
ate as possible – the patient must be looking exactly at the
calibration targets. Calibration should be verified by passive
low frequency movements of the patient’s head horizontally
from side to side slowly as the patient fixates a central fix-
ation spot on the wall in order to verify that the eye vel-
ocity and head velocity traces superimpose.
3. Pupil image. The computer data acquisition program
tracks the centre of the pupil, so the pupil must be clear
and sharp and not obstructed by eye lids at any part of the
head impulse. In patients where the eye lids partially
obscure the pupil it is necessary to lift the eye lids, even
using medical tape to tape them up, or to reposition the
goggles to yield an obstruction-free image, or to use a target
a little below or a little above, to minimize reflections into
the pupil. Emphasize to the patients to keep their eyes wide
open and to try not to blink during the head turn.
4. The head turn is ‘turn and stop’. Do not overshoot or
rebound. This needs practice.
5. It is vital that the operator gives head turns with high
enough velocities – at least 150 /s. If the peak head velocity
is only 100 /s (or less) then even unilateral patients can
appear normal because at low peak head velocities the
healthy ear can generate normal smooth compensatory eye
velocity.
6. Verify that the patient can see the target without their
spectacles, and that they understand the instructions. This
is especially true of people who have language difficulties or
senior subjects or subjects whose attention wanders.
Encourage the patient and give them continual feedback
during the test.
7. The head impulse. The operator places their hands on
the top of the patient’s head and turns the patient’s head in
an abrupt, unpredictable, horizontal head turn and stops
abruptly so the patient’s nose points to an imaginary target
within a range of about 10 to the left or right of the
patient’s straight ahead.
8. For testing vertical canals, the patient’s gaze must be
aligned with the plane of the canal under test. The head
impulse is delivered in that canal plane but the gaze should
not be straight ahead, but along the plane of the canal
under test.
9. Instructions. For HIMPs, the patient is instructed to
keep staring at the fixation target on the wall in front of them
during the head turn and to return their eyes to that target as
quickly as possible if they lose the target. For SHIMPs, they
fixate a head-fixed target. They are also instructed to try not
to blink (‘keep your eyes wide open’), to relax their neck
14 I. S. CURTHOYS AND L. MANZARI
muscles (become like a ‘rag doll’); not to ‘help’ with the head
turns and not to try to guess what will be next.
10. How many impulses? Every head turn is a separ-
ate test of vestibular function of the semicircular canal
on the side to which the head is turned. Every extra
head turn in that direction just repeats the same test.
With many patients the results are very clear in the first
2 or 3 impulses, and the extra impulses just add to the
operator’s confidence. It is better to aim for a small
number of quality head turns than religiously going
after an impossible 20. It is the quality of the impulses,
the quality of the abrupt start and stop, the peak head
velocity, not the number of impulses, which is
important.
11. How fast? It is necessary to give some stimuli with
velocities of at least 150 /s. If only low velocity (and so low
acceleration) head impulses are used the opposite (healthy)
ear can drive the eye movement response. That is why high
acceleration stimuli are mandatory. Overshoot (and
rebound) should be minimized.