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The lack of a catch-up saccade during head impulse testing tells us that her vestibulo-ocular reflex is presumably intact and, therefore, she likely does not require adaptation exercises. In reality, there are some weeds that make this messier – but they are likely beyond the scope of the NCS. If the patient did not have so many signs of motion sensitivity and she reported symptoms only during head impulse testing but still did not have an overt retinal slip, I would consider implementing gaze stabilization exercises for the purposes of adaptation.

Additionally, if the patient doesn’t respond to physical therapy interventions, I might recommend more sophisticated testing. Some physical therapy clinics can do video head impulse tests (vHIT) that can detect covert catch-up saccades that would indicate an abnormal VOR that is not observable without equipment. Audiologists who complete full vestibular function test batteries can also do vHIT – and I might recommend complete vestibular function testing for this patient that would quantify how well the peripheral vestibular system is functioning and detect any asymmetries. Vestibular function testing is summarized in the vestibular lecture under “diagnostic and medical management”.