What is the Hallie maneuver and how is it performed?

Clarification: There is No "Hallie Maneuver" in Medical Literature

The term "Hallie maneuver" does not exist in established medical practice—you are likely referring to either the Dix-Hallpike maneuver (diagnostic test for BPPV) or the Heimlich maneuver (for choking/foreign body obstruction). Based on the context of vertigo and balance disorders in the provided evidence, I will describe the Dix-Hallpike maneuver, which is the gold standard diagnostic test for posterior canal benign paroxysmal positional vertigo (BPPV). 1, 2

The Dix-Hallpike Maneuver: Step-by-Step Procedure

Pre-Procedure Counseling

• Warn the patient that the maneuver will provoke sudden, intense vertigo and possibly nausea, which typically subsides within 60 seconds. 2
• Ensure the patient understands this is a diagnostic test to identify the cause of their positional vertigo. 1

Patient Positioning

• Position the patient seated upright on the examination table, far enough back that when supine, their head can extend ("hang") approximately 20 degrees off the posterior edge of the table. 1, 2
• Ensure you can safely support the patient's head throughout the entire maneuver. 2

Performing the Maneuver (Testing One Side)

1. Turn the patient's head 45 degrees toward the ear being tested (e.g., right ear). 1

2. Rapidly move the patient from sitting to supine position while maintaining the 45-degree head turn, allowing the head to extend 20 degrees below horizontal off the table edge. 1, 2

3. Observe for 30-60 seconds while:

   • Asking about subjective vertigo symptoms
   • Watching for characteristic torsional (rotatory), upbeating nystagmus
   • Noting any latency period between positioning and symptom onset 1, 2

4. Return the patient to sitting position slowly. 2

Testing the Opposite Side

• Repeat the entire sequence with the head turned 45 degrees to the opposite ear (e.g., left ear). 1
• The maneuver must be performed bilaterally to determine which ear is affected. 2, 3

Interpreting Results

Positive Test (Diagnostic for Posterior Canal BPPV)

• Torsional, upbeating nystagmus appears after a brief latency period
• Vertigo is provoked simultaneously with nystagmus
• Symptoms increase then resolve within 60 seconds
• The affected ear is the one positioned downward when symptoms occur 1, 2, 3

Negative or Atypical Results

• If horizontal nystagmus or no nystagmus occurs despite compatible history, perform a supine roll test to assess for lateral semicircular canal BPPV (10-15% of BPPV cases). 1, 2
• A negative test does not definitively rule out BPPV—consider repeating at a separate visit (negative predictive value only 52% in primary care). 1, 2

Critical Safety Precautions

Absolute or Relative Contraindications

Exercise extreme caution or avoid the maneuver in patients with:

• Significant vascular disease or risk of stroke 1, 4
• Cervical stenosis or severe cervical spine pathology 1, 2, 4
• Severe kyphoscoliosis 1, 2
• Limited cervical range of motion 1, 2
• Down syndrome (atlantoaxial instability risk) 1
• Severe rheumatoid arthritis (cervical instability) 1, 4
• Cervical radiculopathies 1, 2
• Ankylosing spondylitis 1, 2
• Spinal cord injuries 1, 2
• Morbid obesity (may require additional assistance) 1, 2, 3

Alternative Approaches for High-Risk Patients

• Special tilting examination tables may allow safe performance in patients with physical limitations. 1, 2

Diagnostic Accuracy

• Sensitivity: 82% and specificity: 71% among specialty clinicians 2, 3
• Positive predictive value: 83% in primary care settings 1, 2
• Lower negative predictive value necessitates repeat testing if clinical suspicion remains high 1, 2