What is the supine roll test?

The Supine Roll Test for Diagnosing Lateral Canal BPPV

The supine roll test is the preferred diagnostic maneuver for lateral (horizontal) semicircular canal benign paroxysmal positional vertigo (BPPV), performed when a patient has symptoms compatible with BPPV but shows negative or horizontal nystagmus on the Dix-Hallpike test. 1

Technique of the Supine Roll Test

• The patient is positioned supine with the head in neutral position 1
• The clinician quickly rotates the patient's head 90 degrees to one side while observing for nystagmus 1
• After any nystagmus subsides, the head is returned to the neutral position 1
• Once any additional elicited nystagmus subsides, the head is quickly rotated 90 degrees to the opposite side, and the eyes are observed again for nystagmus 1
• The test is also known as the Pagnini-Lempert or Pagnini-McClure Roll Test 1

Nystagmus Patterns in Lateral Canal BPPV

Two distinct nystagmus patterns may be observed during the supine roll test:

Geotropic Type (Most Common)

• Horizontal nystagmus beating toward the undermost (affected) ear when rolled to the pathological side 1
• Less intense horizontal nystagmus, again beating toward the undermost ear, when rolled to the healthy side 1
• The side with the strongest nystagmus is typically the affected ear 1
• Likely caused by debris in the long arm of the semicircular canal 1

Apogeotropic Type

• Horizontal nystagmus beating toward the uppermost ear (away from the ground) 1, 2
• Upon rolling to the opposite side, the nystagmus changes direction, again beating toward the uppermost ear 1, 2
• The side opposite the strongest nystagmus is typically the affected ear 1

Clinical Significance

• Lateral canal BPPV accounts for approximately 10-15% of BPPV cases 1
• The supine roll test has high sensitivity (89.47%) for detecting lateral canal BPPV 3
• Patients should be informed that the test may provoke intense dizziness temporarily 1
• The test helps identify the affected ear, which is crucial for selecting the appropriate treatment maneuver 1, 2

Additional Diagnostic Considerations

• In cases where lateralization remains unclear (approximately 20% of cases), additional testing methods such as the bow and lean test may be helpful 1
• The intensity of nystagmus during the supine roll test correlates with prognosis after repositioning maneuvers 4
• Patients with longer latency in the affected side and slower slow phase velocity on the healthy side during testing may have a higher risk of persistent symptoms after treatment 4

Precautions

• Exercise caution when performing the test in patients with physical limitations including cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, Down's syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, ankylosing spondylitis, low back dysfunction, spinal cord injuries, and morbid obesity 1, 2
• Additional assistance may be required to safely perform the maneuver in some patients 1
• Special tilting examination tables may be useful for patients with physical limitations 1

The supine roll test is an essential diagnostic tool that allows clinicians to accurately diagnose lateral canal BPPV, thereby avoiding unnecessary diagnostic tests and inappropriate treatment 1, 2.