Vertigo and Dizziness

Your Guide To Balance Disorders

Jaydip Ray

• Publisher: Sheldon Press
• Year: 2018
• Print ISBN: 9781847094438
• eBook ISBN: 9781847094445
• Topic: Medicine
• Subtopic: General Health

Vertigo and dizziness are extremely common, and cause a great deal of worry and distress. Symptoms may include nausea, tinnitus, hearing loss, blurred vision, confusion, raised temperature and fever. Many people stop work because of balance disorders, while in older people, there is a very real threat of falls. This book, by a distinguished ENT consultant, examines the common and more unusual forms of these conditions. Topics include: the balance system
defining vertigo and dizziness
inner ear disorders, such as labyrinthitis
Ménière's disease
the link with migraine, including vestibular migraine
balance disorders in children
tests and treatments, such as radiology, electrophysiology and injections
surgery and implants
'fear of falling' and psychological strategies to helpProfessor Jaydip Ray says there is plenty that can be done to treat symptoms and improve quality of life, so don't just put up with vertigo and dizziness, seek help today!

 

1

Balance And Posture

Simon Carr

 

‘Balance’ is your ability to maintain the centre of gravity of your body within its base of support, whereas ‘posture’ is defined as the alignment of your body and limbs. There are several types of posture: ‘static’ (standing, sitting and lying, for example) and ‘dynamic’ (such as walking, running and lifting). It is during movements that the balance system is under the most strain.

By design, the human body is a rather unstable machine. Due to the fact that two-thirds of our mass is located in the top two-thirds of the body, furthest from the ground, we are in a constant state of instability and, therefore, reliant on a balance system that is constantly assessing information coming in and adjusting our positioning as a result. This is most apparent when an aspect of the balance system fails, making falls more likely.

Maintenance of your posture and balance relies on the inter- action of several different systems, including your eyes (ocular sys- tem), inner ears (vestibular system), and joints, especially of your legs (proprioceptive system), which interact to sense the environ- ment. The information from these systems then travels to the bal- ance centre of your brain with messages from your joints travelling via the spinal cord, where it is processed. When it reaches your brain, the information from the different systems is pieced together and an appropriate response of the eyes, muscles and joints is performed, all of which take place in a fraction of a second.

 

Eyes (ocular system)

The eyes play a major role and vision is arguably the most important sense for maintaining your balance. Your vision is constantly assessing the surrounding environment that you are either standing in or moving on and the nature of objects around you, the information being fed back to the balance centre in your brain.

 

Inner ears (vestibular system)

The role of your inner ears is to assess movements of your head relative to gravity and the horizon and enable you to keep looking at an object even when your head moves in different directions.

Your inner ears are made up of three semicircular canals and two otolithic (ear stones) organs. The three semicircular canals in each inner ear lie within three different planes: one lateral (horizontal), one posterior (backmost) and one superior (uppermost). They work in pairs: the lateral canals work together and the superior canal works with the opposite posterior canal. The canals are fluid-filled and have an enlarged (ampullated) end, which contains the sense organ (cupula), a jelly-like dome-shaped structure with hair cells protruding into it which are attached to the balance nerve. When you turn your head, the fluid in the canals shifts, which causes the cupula to move, thus moving the hair cells and triggering a signal that travels along the balance nerve. This in- formation is used by your balance centre to tell the brain where the head is positioned in relation to the environment – that is, if the head is tilted or turned to the left or right or looking up or down. This information is used to keep your eyes looking at a particular object when your head is turning and also to enable your eyes to remain stable when your head moves while you are walking or running.

The two otolithic organs are called the saccule and utricle. They are called otolithic organs as they contain small crystals of calcium carbonate. These are embedded into a jelly-like substance with hair cells protruding into it. The saccule detects gravity, whereas the utricle detects horizontal acceleration, such as when you are accelerating in a car. When your body is subjected to vertical acceleration (gravity) or horizontal acceleration (for example, in a car), the gel layer in the organ moves more quickly than the crystals sitting within it, causing the gel layer to distort. This distortion is detected by the hair cells, which triggers a signal that travels down the balance nerve to the brain.

Acting together, the inner ears provide information about the position and movements of your head in relation to what is around you. If you have problems with your inner ears you will be significantly more unsteady in low light conditions, such as when you get out of bed in the night, as your brain will not receive sufficient balance information from your eyes due to the darkness. The only information will come from your joints.

 

Joints (proprioceptive system)

It is essential for the brain to be aware of the position of your arms and legs, particularly the lower limbs, at any moment in time. If your balance is to be maintained on a variety of terrains, then the brain must be able to interpret what actions are required in order to keep you upright. This information is derived from the signals your joints send to your brain via your spinal cord.

 

Brain

The information from all of these systems is processed by a particular region of your brain called the cerebellum, which is situated at the back of the brain. The cardiovascular system (heart and blood vessels) plays an important role in maintaining the blood supply to the brain.

 

What happens when it goes wrong?

Any insult to any part of your balance system will have an effect on your ability to maintain your balance. This can be due to visual problems, such as cataracts, and arthritis, which can affect the proprioceptive system, conditions affecting the vestibular system, such as vestibular neuritis (VN; see Chapter 3), or a problem with the balance centre in the brain, such as chronic alcohol abuse. These systems can also be affected by various medications, such as certain antibiotics (gentamicin, for example) and anti-epileptic medications (such as phenytoin).

If the blood supply to your brain is reduced, you will feel dizzy. The most common cause of this is orthostatic hypotension, which is when the blood pressure doesn’t rise quickly enough on sitting or standing up, resulting in momentary dizziness – a head rush. This can happen as part of the ageing process or can be part of certain conditions, such as diabetes.

As the human body ages, the chance of one or several of these systems developing a problem increases. In the UK, falls are the most frequent and serious type of accident in people aged 65 or over, and are the main cause of disability and the leading cause of death from injury in those aged 75 or over. Every year more than 1 in 3 of the population (3.4 million) over 65 have a fall that can cause serious injury and even death. Fractures sustained as a result of falling are increasing and are even more than the number of people having a stroke or heart attack.

 

2

The Impact Of Balance Disorders

The term ‘dizziness’ is used to describe all manner of balance disorders. The trouble is that balance problems are of various types, differing in onset, duration, severity and frequency. Hence, the impact of each condition will vary and will affect people differently. Remember, dizziness is a subjective symptom that only you can feel. Those around you (even those close to you) may have no idea when you are dizzy and how you might be feeling. It is therefore very useful to share your feelings and experiences with them so that they can appreciate the effect it is having on you.

It is irrefutable that loss of balance has a significant impact on your mobility, confidence and independence. This causes anxiety, stress, depression and may subsequently result in an inability to carry out simple activities of daily living.

The wider impact of dizziness is huge: 30 per cent of the UK population is estimated to experience symptoms of dizziness or imbalance by the age of 65 years and it is the most common reason for visits to a doctor by those aged over 75; 1 in 3 adults in the community has significant dizziness at any given time and up to 14 per cent of people stop work because of imbalance.

Stress can sometimes be both the cause and the effect of dizziness. Stress reactions can be triggered by events in your environment or personal life. The body responds by increasing the release of stress-combating hormones. These are meant to switch on the ‘flight, fight or submit’ mode and can cause an increase in your heart rate and respiration rate, a heightened state of anxiety and arousal with muscle tension, pain and headaches. The hyperventilation itself can cause dizziness and the muscle tension can cause stiffness and reduced mobility exaggerating the dizzy symptoms. This feeds the cycle of anxiety, tiredness, low mood and depression, which then leads to altered behaviour aimed at avoiding activities that bring on the dizzy symptoms. This behaviour can affect your immediate social environment, work or personal relationships.

The common features to look out for are:

• rapid heartbeat
• rapid breathing
• muscle tension
• tightness of the chest
• restlessness
• irritability
• sleep disturbance
• constant tiredness
• loss of interest
• loss of self-confidence
• social withdrawal.

You will already be aware that one of the biggest risks arising from balance disorders is of a fall. Falls in people over 65 years are a leading cause of confinement and death and are termed as one of the ‘giants of geriatrics’.

The social, occupational and economic costs of balance disorders to the individual, society and health services are profound, resulting in repeated medical attendances and costly investigations.

One of the most common features related to dizziness and falls is a ‘fear of falling’. This is a well-known consequence. It sets up a downward spiral of negative thought processes, compounding the problem further as the person curtails various daily activities, which leads to reduced mobility and physical fitness that, unfortunately, further increase the risk of falls and injuries. This also leads to reduced social interaction, depression, isolation resulting in loss of activity, earning and productivity. As we live longer, keeping active and preventing falls is a huge challenge to society.

People with neuro-disability (the impairments an individual can experience following a traumatic brain injury or stroke) also have significant posture, balance and stability issues. Your doctor will usually arrange for a rehabilitation plan through a falls service. This will usually include exploring the history of falls and an assessment of gait, balance, mobility, muscle weakness, osteoporosis risk and functional ability.

If you have a balance disorder, then you will be at a high risk of falling. The risk is hugely increased if you have comorbidities (two or more coexisting medical conditions that are additional to an initial diagnosis) and take lots of medications.

People aged 65 and older have the highest risk of falling, with 30 per cent of people older than 65 and 50 per cent of people older than 80 falling at least once per year. Older women with diabetes (especially those with neuropathy – damage to nerves causing numbness or weakness) have a higher risk of falls and hip fractures.

The human cost of falling to the individual includes distress, pain, injury, loss of confidence and independence, as well as the effects on relatives and carers. According to the National Patient Safety Agency, the healthcare cost for treating falls in England and Wales is estimated to be in excess of £15 million per year. This figure rises to an estimated £2.3 billion per year, however, when associated costs, such as fracture management and long-term care provision, are taken into consideration. Fragility fracture management alone (for any fall from a standing height or less that results in a fracture) is estimated to cost the NHS about £1.7 billion per year, and the major determinant of this cost is length of hospital stay.

Dealing with the problem

Given the implications of dizziness, it is important to have a clear understanding of the background problems and their causation. The next few chapters will help you explore some of these issues in a systematic fashion.

The first step in self-help is relaxation and to adopt fall prevention strategies. Regular exercise to maintain your core strength, stability and mobility is proven to be very beneficial. Making sure your glasses are checked regularly and a healthy diet (especially vitamin D) will help. If you experience dizziness and instability, an uncluttered environment free of trip hazards will help to prevent injuries. Other areas to address are footwear and lighting.

Dizziness and its related problems set up automatic reactions that are linked to negative thoughts. As previously discussed, there is a combination of anxiety, depression, anger and guilt.

Other problems are rumination, avoidance and denial. Here you end up going round and round in circles thinking about the dizziness itself and the impact it has on you instead of focusing your energy on addressing measures that might help resolve the problem. This reduces your motivation to engage in solutions and keeps you perpetually in your current state. It also pushes you to avoid all movement and become less and less mobile. There is some evidence that mindfulness and cognitive behaviour therapy might help you to understand your condition better and motivate you to engage with the rehabilitation strategies.

It is important to remember that some balance disorders (as you will see shortly) may be chronic. While a quick-fix cure may not exist yet for the majority of conditions, a lot can be achieved by self-help strategies, motivation and long-term engagement with therapy to control the symptoms.

One useful strategy might be to take charge of your own health and well-being, address the problems as t...

Table of contents

• Acknowledgements
• Introduction
• 1
• Balance And Posture
• 2
• The Impact Of Balance Disorders
• 3
• Common Conditions
• 4
• Other conditions
• 5
• Balance Issues In Older People
• 6
• Medicines
• 7
• Balance Disorders In Children And Teenagers
• 8
• Assessment Of Balance And Stability
• 9
• Newer Tests
• 10
• Rehabilitation
• 11
• Neurosurgical and other treatment strategies
• 12
• Psychological factors
• 13
• Visual Vertigo
• 14
• The Future And Research
• Useful addresses
• References and further reading
• About the Author