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Table of Contents
ORIGINAL ARTICLE
Year : 2015  |  Volume : 17  |  Issue : 2  |  Page : 49-51

Stepping test; is it effective for diagnosis of labyrinthine dysfunction?


1 Medical student, Department of ENT, College of Medicine, King Faisal University, Saudi Arabia
2 Assistant Professor, Department of ENT, College of Medicine, King Faisal University, Saudi Arabia
3 Professor, Department of ENT, College of Medicine, King Faisal University, Saudi Arabia

Date of Web Publication2-Jan-2020

Correspondence Address:
MD Kamal-Eldin Ahmed Abou-Elhamd
ENT Professor College of Medicine, King Faisal University. Al-Ahsa 31982, Box 400
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.274657

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  Abstract 


Objective: The aim of this study was to evaluate the value of stepping test in diagnosis of labyrinthine dysfunction
Study design: A cross sectional study. Methods: A random sample of 50 female medical students, from second to fifth grade (22 +/- 2 year old) at college of medicine, King Faisal University, Saudi Arabia in May 2014 were examined by the stepping test.
Results: Out of 50 students, 27 (54%) showed positive test, 6 of them (12%) were complaining of frequent vertigo, while 21 of them (42%) have no complaint related to the ear.
Conclusion: Stepping test is not an effective diagnostic tool for inner ear pathologies. The rotational movement as a positive result, has almost an equal sensitivity but higher specificity than the forward movement. We suggest to consider the test is positive only when both the forward and rotational movements are positive, or at least the rotational movement is positive but not the forward movement. This will increase the sensitivity and specificity of the test.

Keywords: stepping test; Unterberger test; Fukuda test; vertigo; dizziness; labyrinthine dysfunction


How to cite this article:
AlDheferi MA, Al jabr IK, Abou-Elhamd KEA, AlMqrab FJ. Stepping test; is it effective for diagnosis of labyrinthine dysfunction?. Saudi J Otorhinolaryngol Head Neck Surg 2015;17:49-51

How to cite this URL:
AlDheferi MA, Al jabr IK, Abou-Elhamd KEA, AlMqrab FJ. Stepping test; is it effective for diagnosis of labyrinthine dysfunction?. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2015 [cited 2022 Dec 8];17:49-51. Available from: https://www.sjohns.org/text.asp?2015/17/2/49/274657




  Introduction Top


Stepping test, also referred to as Unterberger or Fukuda test, is used to assess labyrinthine function in patients with gait instability and vertigo. Although the test is more related to neurological examination, two otolaryngologists, Siegfried Unterberger (an Austrian otolaryngologist) and Tadashi Fukuda (a Japanese otolaryngologist) introduced it [1]. In 1938, Unterberger proposed his test to detect patients with vestibular deficits, in which they will display a slow rotatory body movement, if they stand alternately on one and then the other leg, particularly if they changed legs quickly. Later, he asked the patients to step in place with their arms abducted horizontally to distract them from the test and to demonstrate the rotation of the body more clearly [1]. It was named stepping test after the modification made by Fukuda in 1959. Fukuda started to quantify the number of steps, as well as the forward, backward, and rotatory movements and called it stepping test. According to examination of 500 normal subjects, Fukudadetermined most normal subjects could complete 50-100 steps in the original position of the body, but there was forward progression of the body up to 50 cm after 50 steps and 100 cm after 100 steps. Some normal subjects displayed an angle of rotation less than 30° on each side after 50 steps, and 45° on each side after 100 steps. Backwards displacement of the body routinely occurred in normal subjects [1]. Angle deviation of more than 45 degrees or forward or backward movement of more than 100 cm is indicative of unilateral labyrinthine dysfunction.

The third author has taught medical students 17 years that the stepping test is a sensitive test in detecting patients with unilateral vestibular dysfunction especially in acute cases. The first author as a student applied the test on herself and found that she has a positive stepping test, although she did not complain of vertigo before. Then, she started to do the test on her colleagues, and she found a false positive result in most of them.

Our aim of this study was to evaluate the value of stepping test in diagnosis of labyrinthine dysfunction.


  Methods Top


A sample of 50 female medical students, from second to fifth grade at college of medicine, King Faisal University, Saudi Arabia in May 2014 were selected randomly.The exclusion criterion was pregnancy of the student.They were asked if they experienced frequent episodes of vertigo before performing the test. Six of them were complaining of recent history of frequent episodes of vertigo (acute vertigo), whereas 44 of them had no history of vertigo. Stepping test was performed with outstretched upper limbs and closed eyes. Then, the student was asked to step in place for 60 seconds with bare feet. Observation of rotation to right or left, with the angle of the deviation is noted. Observation must also consider any forward or backward movement, and the distance should be measured. If the angle of deviation is more than 45 degrees, or the forward or backward movement is more than 100 cm, the student is considered to have a positive test.


  Results Top


Out of the 50 students, 27 (54%) showed positive test. Out of these 27 students, six of them (12%) were complaining of frequent vertigo, while 21 of them (42%) had no complaint of vertigo as shown in [Table 1] [Figure 1].Out of the six vertigo complaining students, 2 of them (33%) showed more tham one metre forward movement, 2 (33%) of them showed more than 45° rotational movement and 2 of them (33%) showed simultaneous forward & rotational movements.Out of the 21 students who never experienced vertigo, 12 of them (27%) showed more than 1 metreforward movement, 5 of them (11%) showed more than 45° rotational movement, and 4 of them (9%) showed simultaneous forward and rotational movements. Of those showed more than one metre forward movement (20 subjects), 4 (67% of vertigo cases) of them were complaining of vertigo while 16 (36% of non vertigo cases) were not. And of those showed more than 45° rotational movement (13 subjects), 4 (67% of vertigo cases) of them were complaining of vertigo while 9 (20% of non vertigo cases) were not [Table 2] & [Figure 2].
Table 1: Summary of results

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Figure 1: Positive stepping test cases

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Table 2: Positive stepping test cases

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Our study shows that the stepping test has a sensitivity of 100% and specificity of 52.3%. The test has a positive predictive value of 22.22% and negative predictive value of 100%. The 1 meter forward movement as a positive result, has sensitivity of 20%, specificity of 94%, positive predictive value of 67% and negative predictive value of 68%. The 45° rotational movement as a positive result, has sensitivity of 31%, specificity of 95%, positive predictive value of 67% and negative predictive value of 82%.

Statistics analysis

Using SPSS version 19, Crosstab test Pearson Chi-square showed non significant difference with Chi value of 7.612, df of 3 and P value of 0.055.


  Discussion Top


The ability to close one’s eyes and step in placewithout turning depends on normal visual, vestibulospinal and proprioceptive function. Therefore, stepping test evaluates motor reactions of the head and neck that aredependent on vestibular sensory input [2].

Although Fukuda stepping test is widelyused for the diagnosis ofvertigo-associated diseasein neurology and otolaryngology, but its reliabilityis disputed [3]. In a 2011 study, the authors found that stepping test is unreliable as an indicator of the vestibular lesion side especially in acute vertigo stage (less than 3 days) [3]. In that study, abnormaldeviation towards the side of the lesionoccurred in 50.0% of cases (126 patients with unilateral vestibular lesion) and towards theintact side in 24.6% of cases, with 25.4% ofpatients within the normal range. In another study about the sensitivity and specificity of the stepping test in detecting peripheral vestibular dysfunction, the results were disappointing [2]. They concluded that Fukuda stepping test is not reliable screening tool for peripheral vestibular asymmetry in chronic dizzy patients (736 patients).

Our study shows that the stepping test could be positive in a normal subject and most of them experienced forward displacement in Fukuda stepping test, never backward.

Stepping test was positive in healthy population in a reported study in 2004 [4].

It is probable that the test identifies the weaker of the labyrinths (not necessarily has a lesion). Our study is supported by a study which showed no significant difference between the results of the stepping test innormal subjects and those with significant peripheral vestibular deficits [5].

An apparently abnormal stepping test would appearto be a poor indicator of peripheral vestibular dysfunction. Similarly, apparent normal performance of a stepping testdoes not exclude the presence of a peripheral vestibulardefect, but may represent good compensation for such alesion.


  Conclusion Top


Stepping test has limited values as a diagnostic tool in patients with vertigo. It is not specific for the inner ear pathologies. The rotational movement as a positive result, has an equivocal sensitivity but higher specificity than the forward movement.

A bullet point summary:

  • Stepping test is not effective as a diagnostic tool for inner ear pathologies especially in chronic cases.
  • The rotational movement is more efficient than the forward movement in diagnosis of labyrinthine dysfunction.
  • The stepping test could be positive in a normal subject.
  • An apparently abnormal stepping test would appear to be a poor indicator of peripheral vestibular dysfunction.
  • Conversely, apparent normal performance of a stepping test does not exclude the presence of a peripheral vestibular defect, but may represent good compensation for such a lesion.


Acknowledgement:

We would like to thank all female medical students at King Faisal University who voluntarily involved in the study and we would like to thank our colleagueBushra Al-brahim for her help in collecting data and share us her support.



 
  References Top

1.
Grommes C, Conway D. The Stepping Test: A Step Back In History. J Hist Neuroscien. 2011;20: 29-33.  Back to cited text no. 1
    
2.
Honaker JA, Boismier TE, Shepard NT, Shepard NP Fukuda Stepping Test: Sensitivity and Specificity. J Amer Acad Audio. 2009;20:311-314.  Back to cited text no. 2
    
3.
Zhang YB, Wang WQ Reliability of the Fukuda Stepping Test to Determine the Side of Vestibular Dysfunction. J Intern Med Resear, 2011;39: 1432-1937.  Back to cited text no. 3
    
4.
Nyabend A, Briart C, Deggouj N, Gersdorff M. A Normative Study of the Vestibulospinal and Rotational Tests. Advances Physiother. 2004; 6: 122-129.  Back to cited text no. 4
    
5.
Hickey SA, Ford GR, Buckley JG, Fitzgerald O’Connor AF Unterberger stepping test: a useful indicator of peripheral vestibular dysfunction? J Laryngol Otol. 1990;104:599-602.  Back to cited text no. 5
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

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