www.braininjury.org.au - Balance Problems and Dizziness

Newsflash:

Balance Problems and Dizziness - Fact Sheet

Balance problems are very common after a brain injury, and can result in problems with movement even when there is no loss of function in the limbs themselves. A “balance disorder” is a disturbance that causes an individual to feel unsteady, giddy, woozy, or have a sensation of movement, spinning, or floating. It is also possible to have difficulty balancing due to impaired control over the limbs.

Vestibular System

The Vestibular System is the remarkably sensitive system which is responsible for the body’s sense of motion, and its ability to keep its balance and focus the eyes in response to that sense of motion. It is also easily disrupted, both by disease processes and trauma. Although dizziness, nausea and vertigo are very common after an acquired brain injury they are completely missed or ignored in many cases. They can impose an extreme additional burden upon an injured brain. The profound challenges that come with any sense of motion may leave those with vestibular problems literally unable to venture forth.

Balance disorders or deficits can result from:

Blood pressure fluctuations from damage to areas controlling the heart /blood flow;
Contradictory sensory information from the limbs (Proprioception - "The sense of body position"), the eyes or the inner ear, resulting in confusion and disorientation;
Damage to the balance mechanisms in the inner ear;
Damage to the parts of the brain that process, analyse, interpret and control all of these other senses or functions, particularly the Cerebellum (fine motor control) or Parietal Lobes (motor planning and spatial awareness), and;
Impaired function of the limbs or individual joints.

An acquired brain injury is just one of many causes of balance disorders, and injury to the brain may not itself be the cause of a balance disorder. Other causes may include Infection of the inner ear, disorders of blood circulation, and aging. All of these can occur in someone with a brain injury, sometimes as a result of the event that caused the ABI itself, sometimes as a contributing factor to the ABI and sometimes as part of a normal aging process that has been accelerated by the ABI.

There are also defined balance disorders, two of the more common ones being:

Midline Shift Syndrome (MSS) – A constant sense of disequilibrium, difficulty with maintenance of balance, an inappropriate posture and gait, and possibly also perceiving the world in a strange way, for example the horizon may be tilted or walls may be tilted or pressing inwards.
Benign Paroxysmal Positional Vertigo (BPPV) – A brief, intense sensation of vertigo that occurs because of a specific positional change of the head. This can result from looking to the left or right or upwards, and can directly affect such common activities as rolling to get out of bed in the morning, or reaching for an object on a high shelf. “Benign” means non-life threatening, “Paroxysmal” means sudden onset, and “Vertigo” means, of course, dizziness. BPPV can be very frightening. If you witness someone having an attack of BPPV, you will notice jerky movements of the eyes.

Diagnosis

Due to this complexity, it is not possible to say what the cause of a balance disorder in any particular individual is without a thorough and comprehensive medical examination. Such an assessment may start with your GP but can involve the participation of physiotherapists, neurologists, neurosurgeons and optometrists and may require a CT or MRI scan or an EEG reading.

So what are the treatment options?

That depends upon the nature of the balance disorder, and if a specific cause can be identified. If the specific cause is treatable, then that is the best option. This may include dietary changes, such as reducing the intake of sodium, caffeine, nicotine or alcohol, or the introduction of medications such as antibiotics or antispasmodics.

Another treatment option, to address the balance directly, is vestibular rehabilitation – balance retraining exercises. These exercises must be customised to the specific patient, and a program needs to be drafted by professionals with knowledge and understanding of the vestibular (balance) system. This treatment is particularly effective with BPPV, which does not respond well to medication. These exercises may be combined with electrical stimulation or biofeedback to more effectively train the muscles. In the case of unilateral Hemiplegia (weakness on one side of the body), altering the centre of balance so that the affected limbs do not have to carry as much weight may also help. Physical aids in addition to therapy can include orthotics such as braces, splints or moulded shoe inserts.

One possible treatment for midline shift syndrome is a concept called “yoked prism reorientation”. Prisms are placed in the patient’s line of sight and rotated so that the patient’s sense of space and orientation is disrupted. This can force the brain to “refocus” and regain a sense of balance.

Other treatments involving training the brain can include training an individual to rely more heavily on Visual cues if proprioception can no longer be completely trusted. In extreme cases of absence of proprioceptive senses, individuals have been able to walk normally with the aid of visual feedback but are unable even to stand if deprived of vision.

Invasive surgical procedures that may be used can include correction of joint or limb contraction, shortening or lengthening limbs or, in some cases, severing proprioceptive nerves to prevent contradictory feedback.

None of these techniques, as useful and effective as they can be, should happen in isolation. Environmental modifications, such as the addition of handrails in the home or the use of a walking stick or frame, and safety education, are also desirable.

If you have a balance disorder, there are steps you can take to improve your chances of a speedy and accurate diagnosis: Write down all your symptoms, being as specific as you can, and take that list to your next appointment with your doctor, physiotherapist or rehabilitation adviser. The list should mention what you were doing at the time of your symptoms, what else was happening, what time of day, etc. Also make sure that you take a list of all your medications – the balance disorder may be caused by an inappropriate medication or by an interaction between different medications.

Coping Strategies

If you have not yet been able to access treatment, or if it is not yet working, there are some tips you can follow to improve your quality of life while suffering from a balance disorder:

Don’t use alcohol and other drugs
Get out of bed slowly in the morning, allowing your body time to adjust to postural changes.
Stop the moment dizziness starts and sit or lie down until it passes
Avoid or slow down problematic movements or change your Environment
Sleep without a pillow to keep your neck and backbone perfectly straight
Cut down on salt as this can increase the sensation of vertigo
Try to pinpoint times or conditions where you are more likely to get dizzy, and use that information to avoid conditions that Trigger dizziness or schedule your day around difficult times.