![Peter Johns](/img/default-banner.jpg)
- 60
- 7 453 980
Peter Johns
Canada
Registrace 3. 09. 2007
Hi, I'm Peter Johns, an emergency physician practicing in Ottawa Canada.
I film, edit, write and create all of these videos myself.
I film, edit, write and create all of these videos myself.
Myths and Misinformation about vertigo
I use clips from recent youtube videos to show that not all vertical nystagmus is central, and the correct description of what a positive Dix-Hallpike test looks like.
zhlédnutí: 1 675
Video
What to do after the epley maneuver? Is your patient cured?
zhlédnutí 9KPřed 7 měsíci
The best way to know if your Epley maneuver worked is to re-test the patient with the Dix-Hallpike Test. I'll go through what the outcomes of re-testing might be and what to do for them.
The HINTS exam - quick review
zhlédnutí 20KPřed 10 měsíci
Describes what you must see and what you cant' see to diagnose a patient with vestibular neuritis.
Why are we still confused about how to use the HINTS exam?
zhlédnutí 16KPřed rokem
In this video I cover: 1. How and why to screen for central features in vertigo patients 2. What you need to see in order to discharge someone with a diagnosis of vestibular neuritis 3. Why you shouldn't do the HINTS exam on patients without nystagmus 4. What to do with those patients with constant dizzy and no nystagmus Grace-3 link www.saem.org/publications/grace/grace-3 My video on vestibula...
How to look very carefully for nystagmus by using a blank piece of paper
zhlédnutí 28KPřed rokem
The nystagmus in peripheral causes of vertigo can be suppressed by visual fixation. I show how you can do with with a blank piece of paper using real patient videos. I also show the elements of the HINTS exam and how it can be used to diagnose vestibular neuritis reliably.
Can nystagmus that changes direction with gaze ever be benign?
zhlédnutí 14KPřed rokem
End gaze nystagmus is a benign cause of nystagmus that changes direction with gaze. It's compared to bidirectional (direction changing) gaze evoked nystagmus which is always concerning for a central cause.
What ear does the nystagmus in vestibular neuritis beat towards?
zhlédnutí 81KPřed 2 lety
Some anatomy and physiology and clinical significance is discussed
Hi Res version of How to diagnose vestibular neuritis
zhlédnutí 12KPřed 2 lety
This a high res version of the video published in Sept 2021. When patients present with constant dizziness and nystagmus, screening for central features and then performing the HINTS plus exam can reliably diagnose vestibular neuritis and allow you to safety send these patients home.
Hi Res Myth Busted again! Central vs Peripheral Tables of Vertigo
zhlédnutí 2,3KPřed 2 lety
This is just a higher resolution version of a recently published video, otherwise the same. My more detailed original video from a year ago about this: czcams.com/video/0FL377pUIlA/video.html My CMAJ article www.cmaj.ca/content/192/8/E182 My Big 3 of Vertigo video showing a much more useful approach for the novice vertigo learner: czcams.com/video/MwbqJvMDonU/video.html
End Gaze Nystagmus
zhlédnutí 41KPřed 2 lety
There is no spontaneous nystagmus in primary gaze (looking straight ahead). Small beats of nystagmus are seen when he is directed to extreme lateral gaze. These disappear when he is asked to move his gaze in slightly. This is end gaze nystagmus, a normal variant and not pathological.
Myth Busted again! Central vs Peripheral Tables of Vertigo
zhlédnutí 19KPřed 2 lety
The myth that a table of the characteristics of Central vs Peripheral causes of vertigo is a useful one keeps popping up. So I use the example of a recently published youtube video to show why these tables only spread misinformation and are dangerous. My original video about this: czcams.com/video/0FL377pUIlA/video.html My CMAJ article in PDF: www.cmaj.ca/content/cmaj/192/8/E182.full.pdf My Big...
How to perform the Head Impulse Test, the most important part of the HINTS plus exam
zhlédnutí 18KPřed 2 lety
Detailed description of the physical elements that must be done to perform the Magic Move of Vertigo, the Head Impulse test.
Dix-Hallpike test of left posterior canal BPPV, before and after Epley maneuver
zhlédnutí 29KPřed 2 lety
I managed to perform the maneuvers myself, while filming with my iPhone. Other than almost poking her in the eye, it worked quite well!
How to screen for central features and use HINTS plus to diagnose vestibular neuritis
zhlédnutí 11KPřed 2 lety
How to screen for central features and use HINTS plus to diagnose vestibular neuritis
The nystagmus in a positive Dix-Hallpike, 100th anniversary! Special guest Dr. Glaucomflecken!
zhlédnutí 14KPřed 3 lety
The nystagmus in a positive Dix-Hallpike, 100th anniversary! Special guest Dr. Glaucomflecken!
Vertigo Myth: BPPV = Dix-Hallpike test, the patient gets dizzy, and you see nystagmus
zhlédnutí 20KPřed 3 lety
Vertigo Myth: BPPV = Dix-Hallpike test, the patient gets dizzy, and you see nystagmus
Vertigo myth: Central vs peripheral tables help you make the diagnosis in vertigo
zhlédnutí 19KPřed 3 lety
Vertigo myth: Central vs peripheral tables help you make the diagnosis in vertigo
What about posterior circulation TIA's?
zhlédnutí 7KPřed 4 lety
What about posterior circulation TIA's?
Vertigo myth: "All vertical nystagmus is central in origin"
zhlédnutí 6KPřed 4 lety
Vertigo myth: "All vertical nystagmus is central in origin"
Can BPPV present with spontaneous nystagmus?
zhlédnutí 7KPřed 4 lety
Can BPPV present with spontaneous nystagmus?
Clinical diagnosis of vestibular neuritis using the HINTS plus exam
zhlédnutí 51KPřed 4 lety
Clinical diagnosis of vestibular neuritis using the HINTS plus exam
Clinical diagnosis and treatment of BPPV using the Dix-Hallpike test and Epley maneuver
zhlédnutí 24KPřed 4 lety
Clinical diagnosis and treatment of BPPV using the Dix-Hallpike test and Epley maneuver
What is the sensitivity and specificity of the Dix-Hallpike Test?
zhlédnutí 3,8KPřed 4 lety
What is the sensitivity and specificity of the Dix-Hallpike Test?
Why you shouldn't do the HINTS exam on patients who DON'T have nystagmus
zhlédnutí 13KPřed 4 lety
Why you shouldn't do the HINTS exam on patients who DON'T have nystagmus
What does an abnormal head impulse test look like?
zhlédnutí 78KPřed 5 lety
What does an abnormal head impulse test look like?
What does a positive Dix-Hallpike look like?
zhlédnutí 22KPřed 5 lety
What does a positive Dix-Hallpike look like?
Dix-Hallpike test revisited: Were Dix and Hallpike wrong?
zhlédnutí 5KPřed 5 lety
Dix-Hallpike test revisited: Were Dix and Hallpike wrong?
Vestibular Migraine- A very common but rarely diagnosed cause of vertigo
zhlédnutí 54KPřed 5 lety
Vestibular Migraine- A very common but rarely diagnosed cause of vertigo
The most authentic, well researched and easily explained vertigo resources. You are the biggest vertigo authority on globe sir....
How to differentiate between labyrinthitis and vestibular neuritis?
So labyrinthitis is where the same dizziness/vertigo (worse with head movement) nystagmus, nausea/vomiting and difficulty walking is present, but also there is hearing loss and/or tinnitus. The real question is: How do you differentiate labyrinthitis from an AICA stroke? And here is my answer on that. Labyrinthitis is rarer than vestibular neuritis. I'd say I see 20 cases of vestibular neuritis for every labyrinthitis. In labyrinthitis, you have hearing loss or tinnitus, while in vestibular neuritis you do not. People often mistakenly refer to vestibular neuritis as labyrinthitis. What the incidence is of labyrinthitis vs an AICA stroke presenting with hearing loss, vertigo and abnormal HIT is not known. If someone had a viral URI, developed ear pain and then tinnitus or hearing loss and vertigo, with no concerning features or risk factors for posterior circulation stroke, and I saw an abnormal HIT, as well as unidirectional nystagmus and no skew, I'd probably call it viral labyrinthitis and send them home. Unless of course they had other central features. If an older person or with stroke risk factors developed a sudden onset of vertigo and hearing loss at the same time, without URI or ear pain, and had an abnormal HIT, and a new hearing loss, I would work them up for AICA stroke. Every other patient in between these two scenarios is going to depend on your resources, your tolerance for risk, and local practices.
@@PeterJohns Thanks good explanation
I was just diagnosed with this after 6 months of almost constant vertigo. Thankful my doctor was familiar. Hoping to finally start feeling better. Thank you for the very easy to understand video.
I am a family medicine resident in Greece, currently finishing my training in a primary care setting. Within a year, I have cured about 15 to 20 patients presenting with posterior canal BPPV and every time patients are extremely surprised and impressed, when I test again with the Dix-Hallpike test and no vertigo is triggered! I always recommend your videos to the rest of my colleagues. Thank you for providing all this content for many others out there, for a medical topic many family doctors are afraid to encounter.
That is very wonderful to hear. The highest kind of compliment is to hear that you have learned to help people. Thank you!
It's the best video for vertigo. Thank you so much!
under rated video
Ha! I didn't know it was rated!
Thanks for sharing!
Thankyou for the educational video
Thanks doc!
It seems there may be far too many healthcare professionals who tend to be eager to believe something is or is probably an inner ear issue when there is no evidence of a stroke in MRI when in reality it is Ataxia.
Haven't seen a lot of that myself.
Australian 😂
Yes, oddly both videos came from down under.
@@PeterJohnsI work in an Australian ED and I’m constantly amazed by the number of dizzy patients referred for CT and further neuro work up /admission by clueless ED docs who can’t do a proper evaluation of the dizzy patient. You should visit down under and do some teaching 😂
Another gem! I (a PT/physio) am going to be giving an hour talk on BPPV to family practice residents in about a month. Hoping it's ok to reference your content!
I'm a PT with an interest in vestibular rx but no formal education other than self-taught. If you see a nystagmus with both left and right Dix Hall Pike but one side is significantly more pronounced, do you assume that they have a positive bilateral test? It can be difficult sometimes to tell the direction of torsion, especially if they are not able to open their eyes fully. Also, second question, what is your best way to differentiate between bppv and vestibular neuritis? I've seen patients feel funny with Dix testing but there was no nystagmus but then when I check horizontal gaze they will get nystagmus. The hospital I work at immediately goes into stroke protocol mode no matter what and actually will not even allow me to do Dix Hall Pike until they have had a negative CT
Sorry to hear you practice in such a non-evidence based environment. What kind of nystagmus do you see on both left and right Dix-Hallpike test? Are you familiar with horizontal canal BPPV? czcams.com/video/VRjRTnIw9YE/video.html Vestibular neuritis will almost always have nystagmus at rest, while BPPV will almost never it. Look carefully for nystagmus as I show in this video. czcams.com/video/eGcUTfeHvZg/video.html Doing the DHT on patients with vestibular neuritis may make a patient feel more dizzy and make a non-specific worsening or bringing out some horizontal nystagmus.
You will learn a ton on Dr. Johns' channel. Another resource on CZcams that is more PT-centric (hope it's ok I plug this channel here) is Balancing Act Resources : www.youtube.com/@BalancingActResources If you have access to MedBridge, I highly suggest the courses by Jeff Walter, DPT (he has videos on YT also, I believe, but the Medbridge courses give you CE credit)
TY! I will definitely continue watching your videos and will check out that video series by the PT also. The medbridge series is on my list too. I totally need further education but also need to get a better grasp on the ordering the different assessments that I do.
Thank you for the informative clip. Could you please upload a video clip about Light Cupula? Thank you!
You know, light cupula is not something I have a good grasp on. Someone with experience diagnosing it will have to make a video.
So am i right to say: 1) if the patient has vertical resting nystagmus then a hints can be skipped as the pt is already so concerning and will need ct? And 2) the patient who has continuous vertigo and shows no resting nystagmus but has provoked vertical nystagmus is concerning ?
1. Yes, vertical nystagmus at rest is almost always a central cause (very rarely, inferior vestibular neuritis can do it). CT head or CT angio is has very poor sensitivity for posterior circulation strokes, which are the most common central causes of vertigo. So a negative CT head by no means should be reassuring if the patient has vertical nystagmus at rest. The gold standard is a delayed MRI. 2. Many patients with BPPV will complain of a lesser continuous dizziness and have no nystagmus at rest. Patients without nystagmus at rest are OK to do the Dix-Hallpike or supine roll test on, and if the nystagmus is consistent with either posterior or horizontal canal BPPV, then the diagnosis is made. Patients who complain of dizziness and have no resting nystagmus but have a new objective difficulty walking are at high risk of stroke. But it's important to look carefully for nystagmus at rest in patient with complaints of persistent dizziness. Sometimes you only see it if you remove fixation, which can be easily accomplished with a blank piece of paper. czcams.com/video/eGcUTfeHvZg/video.html
Excellent information. I also have 40 years of practice and never heard this before.
Fantastic! When I tell learners that the nystagmus of PCBPPV is vertical upwards I almost universally get a skeptical look and it appears that they begin looking around the ED for an actual doctor 😂
Haha! I remember showing a classic positive DHT to an older ED doc and him going "ooooo....vertical.... that's bad!" I also heard a medical student say that she saw a case of BPPV with another doc and when the nystagmus was vertical, the patient had to have a CT head "just to be sure". Ouch!
@@PeterJohns my favorite is when the learner presents a patient on whom they have (proudly) performed both a DHT and a HINTS, yikes.
@@olympiashorts I heard a neurologist was referred a patient and the referring team said the HINTS exam was "negative". The neurologist asked "just to be clear, what did the head impulse test show?" The answer: "It wasn't done, so it was negative". Doh!
I recently consulted a patient who was admitted to neurology with acute vestibular syndrome with spontaneous left-beating horizontal nystagmus, positive HIT to the right, no skew, no other pathologies because „repetitive Semont manever wasn’t effective”.
@@michamachaa8775 I've seen a woman admitted to neurology for vertigo, had an MRI, and sent home. But was still dizzy moving around! I saw her and diagnosed her with horizontal canal BPPV. Cured her, sent her home.
Always well done, Dr. Johns. (and with massively well known Dr. Glaucomflecken, no less).
How do betahistine and vestibular sedatives affect these tests? Are they useful in patients who are already taking these drugs?
I only use vestibular sedatives if the patient can't tolerate the Dix-Hallpike or Epley maneuver. I'd say I have to use them in about 20% of cases of BPPV. I don't believe they will affect the diagnostic accuracy or effectiveness of the Dix-Hallpike test or the Epley maneuver.
@@PeterJohns thanks... Greatly appreciate your input
I have central vertigo from immunotherapy for brain tumors and can tell you for a fact 1) it came on quickly 2) if definitely fatigues,ie comes on, then gets less...my experience in the last 3.5 yrs is that most doctors don't have a clue, and I'm best doing my own therapy....vestibular therapist have a much better idea of whats going on.
Thank you for clarifying this , I recently very confidently tried to admit a patient with bi directional nystagmus to a Neurologist as central cause and was asked about this very same thing.
Interesting! So they had end gaze nystagmus?
Thank you
This is the first time I have ever seen PMR demonstrated by actual people on video. It really helped
Medical video with million plus views is a huge achievement
I got this at age 47 during chemotherapy. I'm 63 now, my doctor said she wouldn't use steroids. I'm thinking of getting another opinion. I'd love to have some relief from the pain.
Mine have last for over a MONTH….. does this sound like something else? Meaning not Vestibular Migraine. They hit out of the blue , I can feel it start in a matter of 10-30 seconds. Then it ramps up over next hours. It wrecks cognition completely. Makes me feel like a retard. Light and sounds, or really any sensory stimulation is offensive as hell. I can’t explain the level of suffering involved here. I broke my spine 8 years ago. Supposedly a stable compression fractures but wondering if this could possibly have something to do with this?
Benign? WTF! How about the destruction to their lives? Years and years into it, I finally even hear the word uttered by a doc but with no treatment and only a referral for someone another 8 months out……. Your life is already hanging by the threads by that point, then u have to wait another 6-12 months to see a specialist AND then you have to get Thru the years of combo of treatments knowing that some will not work. Years later u MIGHT have found something that helps SOME…. By this time, many years later and MEDICAL GASLIGHTING done to you, your life if already shredded to tiny pieces of not “unliving” yourself already. It’s a LIFE DESTROYER made WORST by the medical industry. I can’t even begin to describe the process in short order than the above. Oh yea, Insanity is likely to set in , IF you are lucky…….
Brilliant. I’ve been using the hints exam. With such a litigation heavy culture, I’m assuming that if documented this would prevent legal trouble out of the gate ? Has that ever been tested?
There is no doubt in my mind that if someone were to document the findings that I outlined in this video, that it would be very strong evidence that the examiner did a very through and thoughtful evaluation. And really, writing a good medico-legal chart is is simply performing a good evaluation and documenting that you did so. I am not aware of any published papers that looked at the ability of any approach to vertigo with regards to preventing a lawsuit.
Thank you very much!
I had a migraine that came on with aura one week ago. I’ve been feeling unsteady ever since, my vision is off. This is describing my last week to a T
Excellent video.
This gave me the most information I have ever been able to find. I wish I could see this doctor. If I don’t get this level of care, I will go see this dude.
Thanks. I am no longer in clinical practice. Still active in vertigo education for medical professionals though.
Thanks!
Thank you!
Absolutely amazing . Straight to the point and clear explanations
Is it up beating torsion nystagmus??
Yes, but i prefer the term "vertical upward and torsional towards the downward ear". This emphasizes that vertical upward nystagmus during the Dix-Hallpike test is a normal thing to see, and not indicative of a central cause. Many unwarranted and useless CT scans of the head have been done on patients with BPPV because the examiner thought that all vertical nystagmus is worrisome for a central cause.
Excelente gracias por la recomendacion
Thank you! ER doc here, and I've noticed this on multiple patients lately when trying to assess for nystagmus. The finding confused me bc the nystagmus was "bidirectional" but the rest of the exam and history did not fit at all with a central cause of dizziness. I found a few papers describing this but always try to not to fall into the "I found one paper that supported my gut feeling" trap. Your explanation gives me much more confidence differentiating this benign finding from a red flag for a posterior stroke or other emergency. Very helpful!
I had a stroke brainstem type, afraid it was a brain problem
Peter..Excellent teaching and very clearly shown and explained.
Best ever explanation!
Thank you for the video ! My little sister has this type of nystagmus and i am worried about her can anyone tell me if its normal or not ??
Glasses laka ke rakhu
Thank You !! A year ago I had vertigo for about a month. Last week I got it 10 times worse! I could not sit up or stand 60 sec without getting sick and throwing up. After searching Google I found your video and tried it by myself. OMG! You saved my life!!! Can't believe something so simple fixed an awful case of vertigo. You and your son are awesome! Thank you so so much !!!!
@6:33 "We can't find a nerve problem so she probably has a brain problem, which the did." *RECORD SCRATCH*
Is it possible to have both bppv?
Yous are the God doctor
Thank you so much! Your lecture makes so much sense and can be easily performed!
Love your videos! In case of using a vestibular sedative like sulpiride in the last 24h, and the patient has no nystagmus. Do you do the HINTS? And would it be affected by it?
I've seen studies show that vestibular sedatives can decrease the amplitude of the nystagmus, but I've never seen a study showing that it would completely suppress it. I've remove fixation with a piece of paper if I didn't see nystagmus at rest.
The secret is in waiting 2 minutes b4 the next movement for the Epley to really work!! Dr. Johns after 4 months I can only say Thank you a million times!!!
Glad to hear you're feeling better. Mostly people can probably get away with one minute in each position, but I don't think it hurts to do 2 minutes.
Doc, why the vertical vor and torsional arent frequently tested like the horizontal? And one more question if you let me, why the torsional vor has different behavior depending on the speed of head tilt. For example, if the head is tilted very fast to the shoulder, the eyes will have many quick torsional movements to the same side of head tilt, but if the head is move very slowly to the same position there are way less quick torsional eye movements or even none quick torsional eye movements. Thanks
The reason why the head impulse test (HIT) is horizontal is because almost all patients with vestibular neuritis have horizontal nystagmus. Only around 2% of patients with VN will have it affect the inferior portion of the vestibular nerve only. These patients with inferior vestibular neuritis will have vertical nystagmus which is beating away from the forehead. Someone trained in how to use the head impulse test in that direction would come in handy. I am not that person. I'm not sure I can give you a good answer about the second question. I am a retired emergency physician with a keen interest in teaching others how to evaluate vertigo, but I am not a an expert in all things related to vertigo.
@@PeterJohns doc, your answer was brilliant as always. Just one more question, I was curious about the vor with eyes closed and after doing researches it says that it works in total darkness and with eyes closed. In my experience, I noticed that when moving the head to the left with eyes closed, after fixating on a target, my eyes doesn’t move behind my eyelids at all but move right before opening the eyelids, differently from the right side that the eyes moves behind the eyelids. Does the vor actually work with eyes closed, and is it possible/ does it means something to have an asymmetric vor with eyes closed?
@@guilhermenunes8460 No idea. I've never tested the VOR with the eyes closed.
Dr. Johns, You are surely one of the best teachers I have ever come across. Congratulations! And, thanks for your wonderful teaching videos.