Thank you so much Doctor, finally a structured explanation and demonstration! This helped so much for my finals. I can only hope for a resident like you who still finds joy in teaching.
@@PeterJohns I live in Vegas&have been battling sinus problems for quite a long time(the usual symptoms=headaches,sneezing etc),but for a about an yr,i'v been dealing with slight balance issues,(they come&go,slight dizzyness lasting a short time,but I certainly notice it when I'm walking)and I've recently become aware of these exercises so I'm justing getting educated&used to doing them..So Thanx for the demo&,info👍
Thank you from the bottom of the heart❤️ for all these videos that actually matter and help in clinical practice. No text book could make me understood so well.
Had a patient with bilateral posterior BPPV today. Two Epley Maneuvers on the right initially followed by left side treatment. Symptoms resolved. Big fan and thank you Dr. Johns.
Such a clear explanation, thank you. The video of your patient demonstrating the rotary on downward vs vertical on upward component was brilliant as well - haven't seen that in person, so that was really great to see.
Fantastic presentation. For as many patients I've seen with BPPV, probably 2-3 a month in a family practice setting, I can't remember spending much time in med school on this common condition which is fun to diagnose and rewarding to treat in the office. Many of my patients who went thes straight to the ER often get over tested with CT, MRI and overnight stays because a simple Dix Hallpike with a good history wasn't done. Thank you
Thanks! I believe that it should be the standard of care for every health care provider that sees dizzy patients as part of their practice to know how to perform the Dix-Hallpike test and Epley maneuver and NOT perform imaging on patients with posterior canal BPPV.
Very nice explanation thanks doc! You are right as well. We were all taught vertical nystagmus WAS CENTRAL VERTIGO. Threw me off...professor never explained that!
Wonderfully clear transmission of knowledge , that’s my first observation Here is a perspective of someone who is medical,y qualified and a sufferer.Namely , me. The Dix = Hallpike test was very unpleasant with intense vertigo , nausea etc. I understand it’s utility , however. As a patient one can focus on a handheld torch and easily detect the vertical direction of the nystagmus and ,less. easily , the torsional component Performing the Epley manoeuvre is equally unpleasant The half somersault manoeuvre induces less vertigo but this may be a pointer to a lesser effectiveness I performed about 10 of each Epley and half somersault. Finally , it worked. But it may be merely spontaneous resolution. There was no epiphany moment. Be warned , the Epley can , initially, make the vertigo worse. (my observation)
Thanks for this video. I wonder if you can help me. I have something strange happening. my right side ear down triggers the dizziness and nystagmus but the nystagmus rotation is turning toward my left ear?? Would I still treat the right side? TIA
First of all fantastic videos Doctor Johns. Much appreciated. I have a dilemma. After looking at your videos for the posterior anterior and horizontal Canal bppv I decided to test myself since I seem to have pretty much classic bppv symptoms. Very strange thing happened. First of all I tested my left and right ears for posterior Canal bppv using dix-hallpike. This initial testing was negative for both ears. Then I tried using the supine roll test for horizontal bppv and again was negative for both ears. I waited about 10 minutes and figured maybe I had done the procedure incorrectly. I had really been feeling all along that my problem was on my right ear side. So I repeated the dix-hallpike maneuver moving more rapidly and more deliberately tilting my head back to test the right side again and got a very strong nystagmus response which I had my wife recording video with my cell phone camera. After looking at it and studying that short video it appears for all the world that I have right eye horizontal canal bppv and left eye posterior canal bppv. In other words it seems to me the right eye is jumping sideways and the left eye is jumping vertically. Is this extremely uncommon and what would this possibly mean as far as trying to treat it? If it's possible I'd love to send you the short video which is under 20 megabytes and can be sent by text message. Either way I've been chasing this problem for the last three plus years and feel like I may be finally closing in on a possible solution based on your videos and my subsequent testing and Analysis that's been done on me for all other possible culprits causing this problem. Any reply would be greatly appreciated. Only wish you were closer to where I lived and I'd come see you directly! Many thanks. Keith dupriest.
Thanks Doctor, that was a good video. You made it easy to understand, I will try it on myself. I just started bouts of dizziness when I look down it turns to the left and go on for 5 minutes as I keep very still. Can’t figure out what it was, as a 75 year old type 2 diabetic this thing really stops my life. Thanks again
I'm not a medical student or professional but I have just been diagnosed with BPPV. Yesterday I had an appointment at my local hospital's ENT department with a follow up consultation. I have had numerous physiotherapy appointments where they have done this test and the Epley Manouevre and was always curious when they referred to my eyes having a beat. I personally felt twitching but was interested to see what they have seen with me. Thank you for an informative and insightful video.
I hit my head at the gym with an iron bar about 10 years ago. Nearly any head movement at the time for a week or so gave me the most awful nystagmus, room spinning for a good 30 secs. I found a similar video with these movements and a friend helped me get whatever was broken in my ear to a safe resting place. It sorted the nystagmus out good, aside from the odd time rolling over in bed my head would spin during my sleep. Then I made a bad error of judgement earlier today going on a theme park ride. Really anyone who has been through something similar needs to be warned never to try rollercoasters ever again. No vertigo but the motion sickness has lasted about 6 hours now. :(
@@PeterJohns Fairly sure it was, as I'd made the same mistake once before after that incident. Rollercoasters weren't a problem before hitting my head. Though why do you think so?
@@adamsykes5737 Motion sickness is fairly common, and not directly related to BPPV. I went on the "mission to mars" at disney world 15 or 20 years ago, (which is a giant centrifuge) and I didn't get BPPV, but I didn't feel right for a couple of hours. I think that's what you were feeling, and not the 30 second dizziness brought on by lying down/rolling over typical of BPPV.
Are the gaze stability exercises (adaptation exercises), Habituation exercises, Balance and postural control exercisess commonly used for the following conditions : benign paroxysmal positional vertigo (BPPV), Meniere’s disease, and vestibular neuritis ?? Thanks
are bppv,menier disease, vestibular neuritis considered vestibular dysfunction or hypofunction? is the term vestibular dysfunction/hypofunction different problem compared to bppv,vestibular neuritis, meniers disease?
Meniere's is reasonable uncommon in the emergency department which is where I work exclusively. While BPPV is the most common cause of vertigo in every clinical setting. There is an association between BPPV and Meniere's but I haven't seen them in the same patient.
Thank you for the excellent videos nice and clear. I wondered, what do you do with patients that have a history that looks like BPPV and that when you do Dix-Hallpike the symptoms are reproducted but no nystagmus is seen. Do you still treat them with Epley maneuver?
So the dix hallpike test is considered positive only when we see nystagmus during the test and not only when we get vertigo without nystagmus from the test?
Can family doctors do Dix-Hallpike at their practises? But we can provoke the bad diziness in these patients which can be nervous and blame the doctors what you have done. What to do?
Yes, anyone who is trained in how to perform and interpret the DH test can do it. Patients should be told that it can provoke an episode of dizziness, but that once a diagnosis is made, treatment can often be given that provides relief from BPPV (Epley usually).
Hello. These videos are so very helpful in instructing physical therapists. Would you mind if I show and share your videos for educational experiences for students and other physical therapists.
Great video, thanks very much!!! One question: is it possible that patients with BPPV can have negative Dix hallpike? or If patient has vertigo but no nystagmus during dix-hallpike, is it still a positive test? Thanks
That's two questions! :) . But two great questions! If a patient has a history consistent with BPPV, but has no vertigo or nystagmus on DHT, it could mean that they had BPPV and it has resolved spontaneously. If so, the patient shouldn't complain of any more episodes of vertigo when rolling over in bed etc. It could also mean that they have a variant of BPPV, such as Horizontal Canal BPPV. So a supine roll test should be performed. See this video ua-cam.com/users/edit?o=U&video_id=VRjRTnIw9YE It could also mean they have BPPV, but you didn't perform the DHT "crisp" enough. Try repeating it, and ensure the patient lies down as quickly as they can without hurting themselves. Second question, patient has vertigo on DHT, but no nystagmus seen. If a patient has the typical one sided positive DHT, and becomes symptomatic with appropriate latency and duration of symptoms, then they may indeed have "subjective" BPPV and worth trying to cure with the Epley maneuver. Hope this helps!
+Peter Johns Thanks. The entire video was very informative and explanatory. But I have a question. At the end of the video you said not to perform HINTS exam on BPPV patients. Is it because its of no diagnostic value or is it because it can worsen the situation(BPPV)? I mean is it like HINTS exam is not indicated in BPPV or is it contra-indicated in BPPV. Please elaborate.
It is not because it will worsen BPPV. It is because the HINTS exam should only be performed when the patient has ongoing, continuous vertigo AND nystagmus. Because in that situation the differential is basically vestibular neuritis (most likely) or cerebellar stroke. An abnormal HIT is pivotal in diagnosing vestibular neuritis. A normal HIT in the HINTS exam means the patient is likely having a stroke. If you perform HINTS in patients with BPPV you will find a normal HIT which would lead you to believe the patient is having a stroke, which they are not. See my videos on HINTS and HINTS plus.
Thank you for a nice demonstrating video, its much easier to understand then reading it from books... How do you perform these maneuvers in patients with cervical vertebrogenic algic syndrome or some vertebral vascular damage (if known..) to not worsen their symptoms. Or you dont? Thank you for answear
If you can tilt your head back 30 degrees and turn your head 45 degrees to the side without difficulty, then there is no reason to not perform the DHT or Epley maneuver. I'm not sure what you mean by "vertebrogenic algic".
I have sent the video as a file attachment to your email address. Please let me know if for some reason it is not received in proper format. Many thanks again!
thanks! I'm a family doctor on the East coast. Super helpful considering I don't normally see this as often as I'd like. What post epleys instructions do you provide your patients with?(do they need to sit up when sleeping and do you tell them to avoid turning the head on the affected side when sleeping?) Many thanks!
Nicely done Peter. In your other video you state that Dix Hallpike is not for patients with spontaneous or gaze evoked nystagmus - I have had BPPV patients with horizontal gaze evoked nystagmus. Are you implying that gaze evoke nystagmus is a red flag for AVS/VN/stroke? Am I checking gaze evoked nystgmus wrong (ie too lateral?) Thanks scott
Might be that you are seeing end gaze nystagmus. See this video ua-cam.com/video/2Ej3jwgvwMU/v-deo.html Also, you can get pseudo-spontaneous nystagmus in horizontal canal BPPV. ua-cam.com/video/escN39cIFKc/v-deo.html And you can get BPPV in recovering vestibular neuritis. And in a positive Dix-Hallpike, you see nystagmus that is vertical upwards and rotatory towards the downward ear. Is that the nystagmus you have seen?
@@PeterJohns thanks Peter. I must be mistaking end gaze nystagmus for gaze - evoked by checking it at full lateral deviation. Keep up the good work scott
I only use medications when patients are too nauseated to allow the performance of the positioning maneuver (DHT and SRT) and any repositioning maneuvers they need. In my estimation, this is about 20% of patients. I never send them home with any medications.
Some patients with positional vertigo, when we apply dix-hallpike we notice only vertigo but no nystagmus during the test? What to do? Some even show no vertigo and no nystagmus. What to do?
There is something that is termed "subjective BPPV", where the patient has only one side where they get dizzy, with latency and appropriate duration of dizziness but no nystagmus. Some people think this is common, but have seen it less than 5% of the time. I would treat that with the appropriate Epley maenuver. If the patient has the typical story of BPPV but no nystagmus or dizziness on both sides of the DHT, I would do the supine roll test to look for horizontal canal BPPV. ua-cam.com/video/VRjRTnIw9YE/v-deo.html If the patient has a negative SRT, then I would repeat the DHT, as repeating it can sometimes bring out a positive test when the first one was negative. If that is also negative, it could be a spontaneous resolution of BPPV, or some other diagnosis.
@@PeterJohns Thank you very much. Can dix-hallpike test be positive on both sides? Is it so common? If yes, we have to do epily on both sides too. Right?
@@SarkisKlinik I've never seen a case of bilateral posterior canal BPPV, but certainly it can occur. Seeing horizontal nystagmus on both sides during the DHT is typical of horizontal canal BPPV, and much more common than bilateral posterior canal BPPV. So unilateral PC BPPV is the most common, then unilateral HC BPPV (with bilateral geo or apogeo nystagmus) then bilateral BPPV, often. Bilateral BPPV is often related to significant head injuries, and may be multi-canal. For example left PC, and right HC.
02:48 .. sir, isn’t the posterior semicircular canal responsible for roll? Because the movement at the time mentioned is a yaw as I learnt .. regards sir
Having the patient turn their head 45 degrees to one side puts the posterior canal into a "straight" or 0 degrees in the sagittal plane. So when the patient is then lied supine with the head extended 20 or so degrees, any otoconia in the posterior canal will have exposed to maximal gravitational forces to move them away from the cupula, and produce the vertigo and nystagmus seen in the Dix-Hallpike test. Hope this answer your question.
Very interesting, thanks. Can I ask you why physiologically the HINTS testing is not to be used in an acute vertigo ? (If I understood it correctly as hints helps to distinguish between a suspicion of central vertigo Vs peripheral) Thanks a lot ++
HINTS is only to be used when the patient has constant vertigo AND spontaneous or gaze evoked nystagmus. Watch this video and let me know if you have any questions. ua-cam.com/video/L4nOD8YdV-s/v-deo.html
Dr. Johns...I understand I just missed being seen or treated by you at TOH- General Campus ER on Fri 03 January. According to the resident who treated my BPPV, you were just coming into the ER as I was being discharged. She explained how you would have asked for consent (and I would have given it) to video my episode of BPPV and the subsequent administration of the Epley Manoeuver. It would have been a pleasure to meet you. The BPPV symptoms (left side to right side) started up again after we got home but with no other one sided symptoms. My wife performed the Epley Manoeuver at least eight times in total on Friday afternoon, evening and Saturday morning and afternoon. I have been symptom free since the last time she did the Epley Manoeuver. Is it normal to have to attempt this manoeuver so many times in order to get the crystals back into place? Thank you for any favour of a reply. Mike
Hi Mike. Glad you're feeling better. That seems like a lot of maneuvers! Generally it only takes 1 to 3 maneuvers to clear the crystals. Sounds like you're symptom free for the past 4 days, so I'd say you're cured.
@@PeterJohns - thank you very much for taking the time to reply, Dr. Johns. It's greatly appreciated. I am feeling MUCH better than I was on Friday. Perhaps my wife's technique wasn't perfect but I really admire her willingness to try and to help.
Turn your head to the left before you lie back, then see if you get dizzy when you lie back. Then sit up and repeat with your head turned to the right. With posterior canal BPPV, only one side will get you dizzy (generally). If you get dizzy on both sides, watch my video on horizontal canal BPPV. ua-cam.com/video/VRjRTnIw9YE/v-deo.html
hello sir ,when dixhallpike done at right side.. nystagmus seen with fast component towards left side ..how do we relate this kind..later dixhallpike followed on left side with fast component was seen towards down ear..
Some people prescribe steroids for vestibular neuritis. I personally have never prescribed them as the evidence for it making a difference in patient oriented outcomes is very weak.
@@PeterJohns when we are not sure which type of bppv it is, is there any harm if we perform both Gufoni maneuver and epiley at the same time and recommend the patient to do both maneuvers at home for 1 week with the hope one of them may help?do these manuevers have any side effect if done without corresponding tests?
@@SarkisKlinik Medications for vestibular neuritis should only be prescribed for 3 or so days, to prevent vomiting and allow the patient to eat and remain hydrated. I typically use metoclopramide 10 mg tid prn. Very important not to prescribe any vestibular sedative or anti-emetic for longer than this time.
@@SarkisKlinik I'm a little unclear why you would confused the vertical upward/torsional nystagmus of PC BPPV with the geotropic or apogeotropic horizontal nystagmus seen on both sides in HC BPPV.
I got addmitted to the hospital once and the doctors mentioned that i will survive with this, please advise me how can i do this by my self please note also that i cant open my eyes becuse i will through up..Please advise it is a horrble days Iam passing through
The crystals are a normal part of the inner ear, but become dislodged from the utricle (where they belong) and then end up in the semi-circular canals (where they cause BPPV). Epley puts them back where they belong.
Thank you so much Doctor, finally a structured explanation and demonstration! This helped so much for my finals. I can only hope for a resident like you who still finds joy in teaching.
Thanks! I was a resident once. Last time in 1989!
@@PeterJohns I live in Vegas&have been battling sinus problems for quite a long time(the usual symptoms=headaches,sneezing etc),but for a about an yr,i'v been dealing with slight balance issues,(they come&go,slight dizzyness lasting a short time,but I certainly notice it when I'm walking)and I've recently become aware of these exercises so I'm justing getting educated&used to doing them..So Thanx for the demo&,info👍
I show these videos to my patients before I perform the procedure. Reduces their anxiety and apprehension.
Bilateral explanation was crucial. SO often we forget both sides . Thank you Superb explanation.
What an amazing work! Thank you so much dear Peter! Please keep posting!
thank you! genuinely appreciate clear instructional videos like this -- learning from textbook is much more complicated.
By far the most clear explanation and demonstration of the manoeuvres. Thank you so much!
Thank you from the bottom of the heart❤️ for all these videos that actually matter and help in clinical practice. No text book could make me understood so well.
Had a patient with bilateral posterior BPPV today. Two Epley Maneuvers on the right initially followed by left side treatment. Symptoms resolved. Big fan and thank you Dr. Johns.
I really appreciate the time and effort to deliver such brilliant information so simply and clearly. Thank you so much sir! You are the best
Such a clear explanation, thank you. The video of your patient demonstrating the rotary on downward vs vertical on upward component was brilliant as well - haven't seen that in person, so that was really great to see.
Thanks so much!
Thank you so much! Your lecture makes so much sense and can be easily performed!
Thank you. I was able to assist someone with BPPV this morning.
Can't thank you enough for this
Fantastic presentation. For as many patients I've seen with BPPV, probably 2-3 a month in a family practice setting, I can't remember spending much time in med school on this common condition which is fun to diagnose and rewarding to treat in the office. Many of my patients who went thes straight to the ER often get over tested with CT, MRI and overnight stays because a simple Dix Hallpike with a good history wasn't done. Thank you
Thanks! I believe that it should be the standard of care for every health care provider that sees dizzy patients as part of their practice to know how to perform the Dix-Hallpike test and Epley maneuver and NOT perform imaging on patients with posterior canal BPPV.
Thank you so much, I do learn it. Doctor, you are such a wonderful teacher as well..
wow, your hints video and this one cleared everything up so well. thank you so much
Thank you. Very helpful!
This was a really clear and concise video, thank you Doc!
Thank you for the great presentation.
Another fantastic video helping me in clerkship!
Very nice explanation thanks doc! You are right as well. We were all taught vertical nystagmus WAS CENTRAL VERTIGO. Threw me off...professor never explained that!
Thank you so much sir. Fantastic explanation
Thanks for your effort. Very helpful.
Wonderfully clear transmission of knowledge , that’s my first observation
Here is a perspective of someone who is medical,y qualified and a sufferer.Namely , me.
The Dix = Hallpike test was very unpleasant with intense vertigo , nausea etc. I understand it’s utility , however.
As a patient one can focus on a handheld torch and easily detect the vertical direction of the nystagmus and ,less. easily , the torsional component
Performing the Epley manoeuvre is equally unpleasant The half somersault manoeuvre induces less vertigo but this may be a pointer to a lesser effectiveness
I performed about 10 of each Epley and half somersault. Finally , it worked. But it may be merely spontaneous resolution. There was no epiphany moment.
Be warned , the Epley can , initially, make the vertigo worse. (my observation)
this was a brilliant explanation
Thank you. Your video is really helpful
Thank you! Your videos are amazing!
Thaaanks, greetings from Germany 🇩🇪
Thank you very much for this great Video!!!
Thank you. Excellent instruction. I think I finally know how to identify BPPV and treat it properly.
Great video, very informative. Thanks doc.
You're very welcome!
this is so late but it's okey I though I had to thank you sir it's so good the way you explain and show the whole process you're incredible thank you
Never too late to comment! Thanks for your kind words.
Thanks for this video. I wonder if you can help me. I have something strange happening. my right side ear down triggers the dizziness and nystagmus but the nystagmus rotation is turning toward my left ear?? Would I still treat the right side? TIA
First of all fantastic videos Doctor Johns. Much appreciated. I have a dilemma. After looking at your videos for the posterior anterior and horizontal Canal bppv I decided to test myself since I seem to have pretty much classic bppv symptoms. Very strange thing happened. First of all I tested my left and right ears for posterior Canal bppv using dix-hallpike. This initial testing was negative for both ears. Then I tried using the supine roll test for horizontal bppv and again was negative for both ears. I waited about 10 minutes and figured maybe I had done the procedure incorrectly. I had really been feeling all along that my problem was on my right ear side. So I repeated the dix-hallpike maneuver moving more rapidly and more deliberately tilting my head back to test the right side again and got a very strong nystagmus response which I had my wife recording video with my cell phone camera. After looking at it and studying that short video it appears for all the world that I have right eye horizontal canal bppv and left eye posterior canal bppv. In other words it seems to me the right eye is jumping sideways and the left eye is jumping vertically. Is this extremely uncommon and what would this possibly mean as far as trying to treat it? If it's possible I'd love to send you the short video which is under 20 megabytes and can be sent by text message. Either way I've been chasing this problem for the last three plus years and feel like I may be finally closing in on a possible solution based on your videos and my subsequent testing and Analysis that's been done on me for all other possible culprits causing this problem. Any reply would be greatly appreciated. Only wish you were closer to where I lived and I'd come see you directly! Many thanks. Keith dupriest.
Perhaps send it as a dropbox link to my peterjohns84@gmail.com email?
this is beautiful, thanks Peter
Your videos are amazing.
Thanks Doctor, that was a good video. You made it easy to understand, I will try it on myself. I just started bouts of dizziness when I look down it turns to the left and go on for 5 minutes as I keep very still. Can’t figure out what it was, as a 75 year old type 2 diabetic this thing really stops my life. Thanks again
I'm not a medical student or professional but I have just been diagnosed with BPPV. Yesterday I had an appointment at my local hospital's ENT department with a follow up consultation. I have had numerous physiotherapy appointments where they have done this test and the Epley Manouevre and was always curious when they referred to my eyes having a beat. I personally felt twitching but was interested to see what they have seen with me. Thank you for an informative and insightful video.
thank you so much sir . most valid information
great video, thanks a million
Thank you for the video
Thanks, great video!
You're welcome, and thanks!
fantastic videos!
Thanks!
I hit my head at the gym with an iron bar about 10 years ago. Nearly any head movement at the time for a week or so gave me the most awful nystagmus, room spinning for a good 30 secs. I found a similar video with these movements and a friend helped me get whatever was broken in my ear to a safe resting place. It sorted the nystagmus out good, aside from the odd time rolling over in bed my head would spin during my sleep. Then I made a bad error of judgement earlier today going on a theme park ride. Really anyone who has been through something similar needs to be warned never to try rollercoasters ever again. No vertigo but the motion sickness has lasted about 6 hours now. :(
Not likely related to your previous problem. But thanks for sharing.
@@PeterJohns Fairly sure it was, as I'd made the same mistake once before after that incident. Rollercoasters weren't a problem before hitting my head. Though why do you think so?
@@adamsykes5737 Motion sickness is fairly common, and not directly related to BPPV. I went on the "mission to mars" at disney world 15 or 20 years ago, (which is a giant centrifuge) and I didn't get BPPV, but I didn't feel right for a couple of hours. I think that's what you were feeling, and not the 30 second dizziness brought on by lying down/rolling over typical of BPPV.
Thanks for this class !!!!
This was awesome!
Very clear,thank u sir!
Phenomenal. Thanks a lot.
Nice👍
thank you so much doctor
Thanks Doctor
Are the gaze stability exercises (adaptation exercises), Habituation exercises, Balance and postural control exercisess commonly used for the following conditions : benign paroxysmal positional vertigo (BPPV), Meniere’s disease, and vestibular neuritis ?? Thanks
Thank you so much!!
are bppv,menier disease, vestibular neuritis considered vestibular dysfunction or hypofunction? is the term vestibular dysfunction/hypofunction different problem compared to bppv,vestibular neuritis, meniers disease?
Very helpful thx
Thanks!
You're welcome!
Well explained
Great video - thank you so much! Have you ever seen people with BPPV and Meniere's at the same time?
Meniere's is reasonable uncommon in the emergency department which is where I work exclusively. While BPPV is the most common cause of vertigo in every clinical setting. There is an association between BPPV and Meniere's but I haven't seen them in the same patient.
Thank you for the excellent videos nice and clear. I wondered, what do you do with patients that have a history that looks like BPPV and that when you do Dix-Hallpike the symptoms are reproducted but no nystagmus is seen. Do you still treat them with Epley maneuver?
Thank you
Большое спасибо за видео
Вы очень приветствуются!
So the dix hallpike test is considered positive only when we see nystagmus during the test and not only when we get vertigo without nystagmus from the test?
Hi. So, the doctor keeps saying horizontal and vertical plane. I'm assuming he means the planes relative to the patient, not the exam bed, correct?
Yes, the nystagmus is always described related to the anatomical position of the patient.
Can family doctors do Dix-Hallpike at their practises? But we can provoke the bad diziness in these patients which can be nervous and blame the doctors what you have done. What to do?
Yes, anyone who is trained in how to perform and interpret the DH test can do it. Patients should be told that it can provoke an episode of dizziness, but that once a diagnosis is made, treatment can often be given that provides relief from BPPV (Epley usually).
Hello. These videos are so very helpful in instructing physical therapists. Would you mind if I show and share your videos for educational experiences for students and other physical therapists.
Of course that would be fine.
Great video, thanks very much!!! One question: is it possible that patients with BPPV can have negative Dix hallpike? or If patient has vertigo but no nystagmus during dix-hallpike, is it still a positive test? Thanks
That's two questions! :) . But two great questions! If a patient has a history consistent with BPPV, but has no vertigo or nystagmus on DHT, it could mean that they had BPPV and it has resolved spontaneously. If so, the patient shouldn't complain of any more episodes of vertigo when rolling over in bed etc.
It could also mean that they have a variant of BPPV, such as Horizontal Canal BPPV. So a supine roll test should be performed.
See this video ua-cam.com/users/edit?o=U&video_id=VRjRTnIw9YE
It could also mean they have BPPV, but you didn't perform the DHT "crisp" enough. Try repeating it, and ensure the patient lies down as quickly as they can without hurting themselves.
Second question, patient has vertigo on DHT, but no nystagmus seen. If a patient has the typical one sided positive DHT, and becomes symptomatic with appropriate latency and duration of symptoms, then they may indeed have "subjective" BPPV and worth trying to cure with the Epley maneuver.
Hope this helps!
@@PeterJohns Can BPPV resolve spontaneously at the same day that it appeared?
@@sergeyryabov7262 Absolutely! But probably anterior canal BPPV> horizontal canal BPPV >>much more than posterior canal.
@@PeterJohns Interesting! Thank you for the answer.
+Peter Johns Thanks. The entire video was very informative and explanatory. But I have a question. At the end of the video you said not to perform HINTS exam on BPPV patients. Is it because its of no diagnostic value or is it because it can worsen the situation(BPPV)? I mean is it like HINTS exam is not indicated in BPPV or is it contra-indicated in BPPV. Please elaborate.
It is not because it will worsen BPPV. It is because the HINTS exam should only be performed when the patient has ongoing, continuous vertigo AND nystagmus. Because in that situation the differential is basically vestibular neuritis (most likely) or cerebellar stroke. An abnormal HIT is pivotal in diagnosing vestibular neuritis. A normal HIT in the HINTS exam means the patient is likely having a stroke. If you perform HINTS in patients with BPPV you will find a normal HIT which would lead you to believe the patient is having a stroke, which they are not. See my videos on HINTS and HINTS plus.
Peter Johns Thank you sir. I got it.
Thank you for a nice demonstrating video, its much easier to understand then reading it from books... How do you perform these maneuvers in patients with cervical vertebrogenic algic syndrome or some vertebral vascular damage (if known..) to not worsen their symptoms. Or you dont? Thank you for answear
If you can tilt your head back 30 degrees and turn your head 45 degrees to the side without difficulty, then there is no reason to not perform the DHT or Epley maneuver. I'm not sure what you mean by "vertebrogenic algic".
I read somewhere that there is no vertical nystagmus in someone with peripheral vertigo, can you please elucidate the confusion a little dr
Watch this video and let me know if you have any questions. ua-cam.com/video/V4C_BRNf1EI/v-deo.html
I have sent the video as a file attachment to your email address. Please let me know if for some reason it is not received in proper format. Many thanks again!
Promethazine tablet helps keep from vomit feelings if taken hour or so before maneuvers
Current recommendations are to not use vestibular sedatives routinely, but are an option if needed.
thanks! I'm a family doctor on the East coast. Super helpful considering I don't normally see this as often as I'd like. What post epleys instructions do you provide your patients with?(do they need to sit up when sleeping and do you tell them to avoid turning the head on the affected side when sleeping?) Many thanks!
No, if they are cured, the patient is free from restrictions. . Post maneuver restrictions have not been shown to make a difference in recurrence.
Hi, what does it indicate when you have still spotaneous nystagmus?
Watch this video. ua-cam.com/video/FwUAUtm-_fM/v-deo.html
Nicely done Peter. In your other video you state that Dix Hallpike is not for patients with spontaneous or gaze evoked nystagmus - I have had BPPV patients with horizontal gaze evoked nystagmus. Are you implying that gaze evoke nystagmus is a red flag for AVS/VN/stroke? Am I checking gaze evoked nystgmus wrong (ie too lateral?) Thanks
scott
Might be that you are seeing end gaze nystagmus. See this video ua-cam.com/video/2Ej3jwgvwMU/v-deo.html
Also, you can get pseudo-spontaneous nystagmus in horizontal canal BPPV. ua-cam.com/video/escN39cIFKc/v-deo.html
And you can get BPPV in recovering vestibular neuritis.
And in a positive Dix-Hallpike, you see nystagmus that is vertical upwards and rotatory towards the downward ear. Is that the nystagmus you have seen?
@@PeterJohns thanks Peter. I must be mistaking end gaze nystagmus for gaze - evoked by checking it at full lateral deviation. Keep up the good work
scott
How often do the patient has intense post DHT retest dizziness (supine to sit position ) and how do you avoid this?
Cure them with the Epley.
Are anti-histamines given to supress the vertigo in bppv?
I only use medications when patients are too nauseated to allow the performance of the positioning maneuver (DHT and SRT) and any repositioning maneuvers they need. In my estimation, this is about 20% of patients. I never send them home with any medications.
What is hints testing
Have a look at my other videos. I recommend "The Big 3 of
Vertigo"
@@PeterJohns thank u sir
Some patients with positional vertigo, when we apply dix-hallpike we notice only vertigo but no nystagmus during the test? What to do? Some even show no vertigo and no nystagmus. What to do?
There is something that is termed "subjective BPPV", where the patient has only one side where they get dizzy, with latency and appropriate duration of dizziness but no nystagmus. Some people think this is common, but have seen it less than 5% of the time. I would treat that with the appropriate Epley maenuver.
If the patient has the typical story of BPPV but no nystagmus or dizziness on both sides of the DHT, I would do the supine roll test to look for horizontal canal BPPV. ua-cam.com/video/VRjRTnIw9YE/v-deo.html
If the patient has a negative SRT, then I would repeat the DHT, as repeating it can sometimes bring out a positive test when the first one was negative. If that is also negative, it could be a spontaneous resolution of BPPV, or some other diagnosis.
@@PeterJohns Thank you very much. Can dix-hallpike test be positive on both sides? Is it so common? If yes, we have to do epily on both sides too. Right?
@@SarkisKlinik Did you watch the horizontal canal BPPV video? It's far more common than bilateral posterior canal BPPV.
@@PeterJohns yes, you mean one sided posterior canal bppv is more common than both sided posterior Canal bppv. Right?
@@SarkisKlinik I've never seen a case of bilateral posterior canal BPPV, but certainly it can occur. Seeing horizontal nystagmus on both sides during the DHT is typical of horizontal canal BPPV, and much more common than bilateral posterior canal BPPV.
So unilateral PC BPPV is the most common, then unilateral HC BPPV (with bilateral geo or apogeo nystagmus) then bilateral BPPV, often. Bilateral BPPV is often related to significant head injuries, and may be multi-canal. For example left PC, and right HC.
02:48 .. sir, isn’t the posterior semicircular canal responsible for roll? Because the movement at the time mentioned is a yaw as I learnt .. regards sir
Having the patient turn their head 45 degrees to one side puts the posterior canal into a "straight" or 0 degrees in the sagittal plane. So when the patient is then lied supine with the head extended 20 or so degrees, any otoconia in the posterior canal will have exposed to maximal gravitational forces to move them away from the cupula, and produce the vertigo and nystagmus seen in the Dix-Hallpike test. Hope this answer your question.
@@PeterJohns What an excellent answer 🙏🏻
My eyes bounce side to side. What manouever do I do?
Watch this video. ua-cam.com/video/VRjRTnIw9YE/v-deo.html
Very interesting, thanks. Can I ask you why physiologically the HINTS testing is not to be used in an acute vertigo ? (If I understood it correctly as hints helps to distinguish between a suspicion of central vertigo Vs peripheral)
Thanks a lot ++
HINTS is only to be used when the patient has constant vertigo AND spontaneous or gaze evoked nystagmus. Watch this video and let me know if you have any questions. ua-cam.com/video/L4nOD8YdV-s/v-deo.html
@@PeterJohns thanks a lot.
Dr. Johns...I understand I just missed being seen or treated by you at TOH- General Campus ER on Fri 03 January. According to the resident who treated my BPPV, you were just coming into the ER as I was being discharged. She explained how you would have asked for consent (and I would have given it) to video my episode of BPPV and the subsequent administration of the Epley Manoeuver. It would have been a pleasure to meet you. The BPPV symptoms (left side to right side) started up again after we got home but with no other one sided symptoms. My wife performed the Epley Manoeuver at least eight times in total on Friday afternoon, evening and Saturday morning and afternoon. I have been symptom free since the last time she did the Epley Manoeuver. Is it normal to have to attempt this manoeuver so many times in order to get the crystals back into place? Thank you for any favour of a reply. Mike
Hi Mike. Glad you're feeling better. That seems like a lot of maneuvers! Generally it only takes 1 to 3 maneuvers to clear the crystals. Sounds like you're symptom free for the past 4 days, so I'd say you're cured.
@@PeterJohns - thank you very much for taking the time to reply, Dr. Johns. It's greatly appreciated. I am feeling MUCH better than I was on Friday. Perhaps my wife's technique wasn't perfect but I really admire her willingness to try and to help.
@@PeterJohns is there a way to not be afraid of the vertigo I will get doing these tests? I have been dealing with this for 6 weeks.
When I use the DHP to diagnose my BPPV, the vertigo already triggers when I lay down the bed. How can I diagnose the affected side of my ear?
Turn your head to the left before you lie back, then see if you get dizzy when you lie back. Then sit up and repeat with your head turned to the right. With posterior canal BPPV, only one side will get you dizzy (generally). If you get dizzy on both sides, watch my video on horizontal canal BPPV. ua-cam.com/video/VRjRTnIw9YE/v-deo.html
hello sir ,when dixhallpike done at right side.. nystagmus seen with fast component towards left side ..how do we relate this kind..later dixhallpike followed on left side with fast component was seen towards down ear..
horizontal or rotatory?
rotatory
@@TheYummyjummy Not sure. But if was what you describe it's not consistent with posterior canal BPPV.
Hi, for Which vestibular vertigo are steroids given? Which doses and how long?
Some people prescribe steroids for vestibular neuritis. I personally have never prescribed them as the evidence for it making a difference in patient oriented outcomes is very weak.
@@PeterJohns thanks a lot. what do you prescribe for vestibular neuritis?
@@PeterJohns when we are not sure which type of bppv it is, is there any harm if we perform both Gufoni maneuver and epiley at the same time and recommend the patient to do both maneuvers at home for 1 week with the hope one of them may help?do these manuevers have any side effect if done without corresponding tests?
@@SarkisKlinik Medications for vestibular neuritis should only be prescribed for 3 or so days, to prevent vomiting and allow the patient to eat and remain hydrated. I typically use metoclopramide 10 mg tid prn. Very important not to prescribe any vestibular sedative or anti-emetic for longer than this time.
@@SarkisKlinik I'm a little unclear why you would confused the vertical upward/torsional nystagmus of PC BPPV with the geotropic or apogeotropic horizontal nystagmus seen on both sides in HC BPPV.
I got addmitted to the hospital once and the doctors mentioned that i will survive with this, please advise me how can i do this by my self please note also that i cant open my eyes becuse i will through up..Please advise it is a horrble days Iam passing through
I'm sorry, i can't help you. Please see a health care professional in real life.
Would the crystals dissolve over time? And how long would it take?
The crystals are a normal part of the inner ear, but become dislodged from the utricle (where they belong) and then end up in the semi-circular canals (where they cause BPPV). Epley puts them back where they belong.
Peter Johns How can I prevent these crystals from leaving the utricle? What kind of head movements are most likely to cause them to be dislodged?
@@zakmatew There is no proven method of preventing recurrence. There is no proof that restriction of head movements prevent recurrence.
Peter Johns that’s unsettling.
У пациентки поражены оба канала?
какой пациент?
@@PeterJohns который на видео.
@@user-tf9gz3zw6k Нет, пострадало одно ухо.
@@PeterJohns А какое? Правое и левое? Спасибо, что ответили.
@@user-tf9gz3zw6k Первый пациент: слева, Второй пациент, справа