Application of motor learning theory to teach the head impulse test to emergency medicine resident physicians

The objective was to develop an innovative method of training emergency medicine (EM) resident physicians to perform the head impulse test (HIT) component of the HINTS (head impulse test, nystagmus, test of skew) examination using video-oculography (VOG) device feedback.

Using principles from motor learning theory and Ericsson's framework for expertise, we developed a training innovation utilizing VOG device feedback to teach the degree (10°-20°) and velocity (>100°/s) of head turn required for the HIT. We assessed the technical ability of participants to perform the HIT using the VOG device, without feedback, to count the number of successful HITs out of 20 attempts before, immediately after, and 2 weeks after the training innovation. Participants rated their confidence on a 1 to 5 Likert scale before and 2 weeks after training.

Most participants (11 of 14, 78%) were unable to perform even one successful HIT in 20 attempts before training despite brief verbal and visual instruction regarding the head turn parameters. However, most participants achieved more than one success, in fact, all with at least five successes, immediately after training (13 of 14, 93%) and again 2 weeks after training (nine of 11, 82%). The median (interquartile range) number of successful HITs was 0 (0, mean 0.79) during baseline testing, 7.5 (5.8) immediately after training, and 10 (8.0) 2 weeks after training (p < 0.01, Kruskal-Wallis). The median confidence rating increased from 1.5 (1) before baseline testing to 3 (1.5) after follow-up testing (p = 0.02, Mann-Whitney U).

Prior to motor training, most participants failed to properly perform the HIT. Feedback training with VOG devices may facilitate development of the skills required to properly perform the HIT. Further study is needed to assess the ability to train the interpretive aspect of the HIT and other components of the HINTS examination.