Ask the expert: dizziness and balance problems
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Ask the expert: dizziness and balance problems

I’m David Herdman. I’m a neuro and
vestibular physiotherapist working in London. We use lots of different sensory
systems for our balance and orientation. We use our inner ear balance which
senses movement of our head, but we also use our hearing and we use our vision, so
what we see, and we use the sense that comes from our muscles and joints
which tells us where our limbs are in space. The brain integrates all of
those different senses and helps us to stay upright and balanced and
orientated. So really a disruption in any of those
different senses can lead to a sensation of dizziness or unsteadiness so in
essence there’s quite a lot of things that can cause dizziness. But a common cause
of dizziness is a condition within the vestibular system, so the inner ear
balance mechanisms which has connections through the inner ear, up to the lower
part of the brain and into the upper part of the brain as well where
dizziness is perceived. Demyelinating disease can affect those pathways and
cause dizziness but we also know that people with MS are particularly prone to
a form of vertigo called BPPV – benign paroxysmal positional vertigo and this
causes symptoms of dizziness when they lay down in bed or roll over in bed or
tip the head up in these kind of positions. That can provoke dizziness
just for a short period of time. This is a mechanical problem of the inner ear
and can get better with some specific treatments as well. Usually a physiotherapist would ask
you quite a number of different questions to try to establish what are
the different characteristics of the dizziness, so when it might come on, what
kind of movements might trigger it and how long it would last. Then they
would typically do an examination which involves looking at your eye movements
and certain reflexes of your head and your eyes as well as doing a specific
test for positional vertigo where they lay you down on the plinth and see
whether that reproduces your symptoms. Then they may also go on to look at
your balance and your walking. Then after that they’ll be in a position to
recognise whether some exercises might be able to help you or whether you might
need some further investigations. One of the interventions is called
vestibular rehabilitation. Essentially this is an exercise-based therapy which
involves different eye and head and body movements. The idea is to gradually
desensitise the brain to the movements and the activities that might bring on
dizziness. There are also some other specific treatments for other vestibular
conditions as well which involves specific manoeuvers but essentially
exercise is a key treatment for dizziness and balance problems. Essentially vestibular rehabilitation
works by bringing on dizziness a little bit so that the brain can put it right.
So over time the brain desensitise to the kind of movements and environments
that at one time may have provoked the dizziness in the first place. Generally we avoid medication. Usually it doesn’t really work and also taking medication over a long period
of time can sometimes worsen the problem of unsteadiness and balance. Essentially
some medication that suppresses the vestibular system can actually
delay recovery and affect the parts of the brain that we need to naturally
recover so usually we don’t encourage long-term use of medication, although
there are a few conditions where that can be helpful so it’s worth if you’re
concerned about medication speaking to your doctor. Yes, outside of traditional vestibular
rehabilitation think about any kind of exercise that involves head or full
body rotation or movements. That’s why, for example, I think racket sports are a
really good idea. Also there is some evidence towards Tai Chi due to its
focus on balance postures and those kind of things, but really any kind of
exercise that you enjoy and you engage with. But be specific so it’s got to
challenge your balance. It’s got to be quite difficult in order for you to
improve. That’s a good question.
The brain stem is a complex structure so it depends on what part of the brain
stem is affected and how that might manifest. For example, there are some
eye movement disorders that typically wouldn’t respond to exercise.
Nevertheless in the largest study that’s been completed to date, they looked at
vestibular rehabilitation in people with MS and they compared the results of
people with brain stem lesions and without brain lesions and they found
similar levels of benefit from both of those treatment groups. There was no
significant difference so that suggests that even patients with brain stem
lesions might benefit from vestibular rehabilitation and physiotherapy to
manage their dizziness problems. I think the first one is seek the
appropriate help and try to see a specialist with interest or knowledge of
the vestibular system and that can be a nurse or physiotherapist or sometimes
audiologist as well. It’s often a bit of a myth that dizziness is not treatable.
In actual fact the vast majority of causes of dizziness can be treated
effectively with trained specialists. The second one would be try not to avoid
those movements that bring on the dizziness. It’s very natural and common
that if something brings on dizziness you’re going to try to avoid it but
actually bringing on that dizziness, even in the short term if it makes you feel a
little bit dizzy, can help the brain to recover and reduce
the response to dizziness over time. The third thing is that exercise is
safe, even if it does bring on a little bit of dizziness usually it is safe
and actually it’s part of therapy, it’s part of helping you to get better. But I
think often people go full guns blazing and then they might need to rest up
for longer afterwards so that kind of boom and bust cycle doesn’t necessarily
help. When you’re exercising just start off gradually, starting off with
something very simple and easy and then gradually work up as you can tolerate
more and more.

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