Dizziness and balance problems

A guide for patients and carers

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Possible treatments for dizziness

Many causes of dizziness, like vestibular neuritis, BPPV, post-traumatic and non-specific peripheral vestibular disorders, tend to recover on their own.

However, if you have been referred to a specialist it is likely that your dizziness is not clearing up of its own accord and you will need some form of treatment.

There are various possible treatments for dizziness and balance problems. Your specialist will assess which treatment might be suitable for you.

Vestibular rehabilitation

The key treatment for almost all of the conditions that can cause dizziness is vestibular rehabilitation. The aim of vestibular rehabilitation is to help the development of vestibular compensation.

Vestibular compensation is a process that allows the brain to regain balance control and minimise dizziness symptoms when there is damage to, or an imbalance between, the right and left vestibular organs in the inner ear.

Essentially, the brain copes with the disorientating signals coming from the inner ears by learning to rely more on the alternative signals coming from the eyes, ankles, legs and neck to maintain balance. Vestibular compensation can be successfully achieved even when the damage to the inner ear is permanent.

The key way to assist the development of vestibular compensation is by doing vestibular rehabilitation exercises. These exercises involve movements of the eyes, the head, the upper body, and then the whole body under different visual situations (for example, with the eyes open or closed, or looking at steady objects or a moving ball), on different surfaces and in different environments.

A key factor is that the brain must sense the presence of dizziness or imbalance to begin the process of vestibular compensation. If, for example, you are regularly taking anti-vertigo drugs or lying still in bed, you might not experience dizziness. When the brain does not sense any dizziness or imbalance it does not realise something is wrong and consequently will not begin the process of vestibular compensation.

For this reason, it might be that the physiotherapist or other specialist overseeing your rehabilitation asks you to reduce and eventually stop taking your anti-vertigo medication. This will be done in consultation with your GP.

As you progress in your rehabilitation programme to the more difficult vestibular exercises, you might experience dizziness when you perform them. This should not be seen as a setback or a reason to stop. It just means that an imbalance between your left and right vestibular systems still exists and the exercises you are doing will help your brain detect the imbalance so it can gradually begin to put it right.

However, you should not go to the extreme of trying to induce dizziness by moving or exercising to the extent that you are sick or become exhausted.

Please note that you should not attempt any of these exercises without first seeing a specialist or physiotherapist for a comprehensive assessment, advice and guidance. Your GP can refer you.

Cawthorne-Cooksey exercises

The aims of the Cawthorne-Cooksey exercises include

relaxing the neck and shoulder muscles,
training the eyes to move independently of the head,
practising good balance in everyday situations,
practising the head movements that cause dizziness (to help the development of vestibular compensation),
improving general co-ordination, and
encouraging natural
spontaneous movement.

You should be assessed for an individual exercise programme to ensure you are doing the appropriate exercises. You could ask if it is possible for a friend or relative to accompany you at the assessment. It can be helpful if someone else learns the exercises and helps you with them.

You will be given guidance on how many repetitions of each exercise to do and when to progress to the next set of exercises.

As a general rule, you should build up gradually from one set of exercises to the next. You might find that your dizziness problems get worse for a few days after you start the exercises, but you should persevere with them.

Make sure that you are in a safe environment before you start any of the exercises to reduce the risk of injury.

The exercises might include the following:

1. In bed or sitting:

A. Eye movements (move eyes slowly at first, then quickly)

Up and down

From side to side

Focussing on finger moving from three feet to one foot away from face

B. Head movements (move head slowly at first, then quickly; with eyes open, then closed)

Bending forwards and backwards

Turning from side to side

2. Sitting:

A. Eye and head movements, as 1

B. Shrug and circle shoulders

C Bend forward and pick up objects from the ground

3. Standing:

A. Eye, head and shoulder movements, as 1 and 2

B. Change from a sitting to a standing position with eyes open, then closed

C. Throw a ball from hand to hand above eye level

D. Throw a ball from hand to hand under the knees

E. Change from a sitting to a standing position, turning around in between

4. Moving about:

A. Walk across the room with eyes open, then closed

B. Walk up and down a slope with eyes open, then closed

C. Walk up and down steps with eyes open, then closed

D. Throw and catch a ball

E. Any game involving stooping, stretching and aiming (for example, bowls or skittles)

Gaze stabilization exercises

The aim of gaze stabilization exercises is to improve vision and the ability to focus on a stationary object while the head is moving.

Your therapist should assess you and say which exercises are suitable for you.

1. Look straight ahead and focus on a letter (for example, an E) held at eye level in front of you.

2. Move your head from side to side, staying focussed on the target letter. Build up the speed of your head movement. It is crucial that the letter stays in focus. If you get too dizzy, slow down.

3. Try to continue for up to one minute (the brain needs this time in order to adapt). Build up gradually to repeat three to five times a day.

You can also do this exercise with an up and down (nodding) movement.
Progressions with this exercise can include placing the target letter on a busy background and changing the position of your feet.

Canalith repositioning procedures (CRP)

The aim of Canalith repositioning procedures (CRP) is to treat people with benign paroxysmal positional vertigo (BPPV) by moving particles trapped in the posterior semicircular canal in the inner ear (labyrinth) causing dizziness.

CRP involves a series of head and upper body movements performed by a trained specialist health professional.

The two main CRP treatments are the Epley manoeuvre and the Semont (Semont-Liberatory) manoeuvre. It is important that these manoeuvres are only performed by a trained specialist to prevent the risk of neck and back injuries.

Brandt-Daroff exercises

Brandt-Daroff exercises are a CRP treatment for BPPV that can be performed at home without the supervision of a specialist.

1. Sit on the edge of the bed and turn your head 45 degrees to one side.

2. Quickly lie down on your opposite side (that is, to the left if you turned your head to the right, and vice versa) so that the back of your head behind your ear touches the bed.

3. Hold this position for about 30 seconds.

4. Return to the sitting position.

Repeat on the on the other side, alternating until you have completed six repetitions on each side.

If your GP is not familiar with CRP, contacting some of the organisations listed in the Useful Contacts section of this booklet might be helpful. Further information is available from regional physiotherapy or audiology centres.

Medication

There are various anti-vertigo drugs available that can make you feel better during the initial or severe phases of dizziness. These are the same type of drugs as those used to treat motion or travel sickness.

Anti-vertigo drugs should only be taken for the first few days of an attack of dizziness. This is because long-term improvement depends on vestibular compensation, not tablets.

It might be that you are prescribed tranquilizers to reduce anxiety. Again, it is usually best to use these only for the first few days of an attack of dizziness as the possible benefits are often outweighed by the risks of
addiction and interference with the development of vestibular compensation.

If you have been diagnosed with dizziness and balance problems caused by migraine, your GP or specialist might advise you to take medication to treat the symptoms of migraine (see migrainous vertigo). This might include pain-relief or anti-nausea medication.

Other therapies

Dizziness and balance problems can cause stress, anxiety and worries. If you have experienced dizziness for a long period of time, you might be concerned that you will never recover or that, despite what your doctors are telling you, you might have a serious underlying health problem.

Your dizziness might create worries about going to work or attending social events. You might feel concerned about visiting friends and family, or looking after your children or grandchildren. Many people are anxious about experiencing an attack of dizziness in public and fear the embarrassment it could cause them during everyday activities like going to the shops, eating out at a restaurant, or going to the cinema.

For some people, it might be that stress and anxiety themselves lead to dizziness and balance problems.

Some people feel anxious in stressful situations like crowded public places, or in enclosed or confined spaces. This anxiety can lead to panic attacks. Some people might experience hyperventilation (quickened and excessive breathing) during a panic attack.

Hyperventilation can cause light-headedness and dizziness in people who might not otherwise experience it. For some people, feeling tense or stressed is enough to make them feel dizzy even if they do not experience panic attacks and hyperventilation.

You should speak with your GP for advice on coping with stress and anxiety. It might be that you are referred to a counselling service. Cognitive Behavioural Therapy (CBT) can be helpful for people experiencing stress, anxiety or depression. Relaxation therapy or breathing exercises can be helpful to reduce stress and anxiety and allow people to feel more in control of otherwise difficult situations.

Surgery

Only a very small minority of people with dizziness and balance problems will need surgery to improve their symptoms. The type of operation will differ according to each individual situation and the particular surgery in which the ear, nose and throat (ENT) surgeon specialises.

Surgery will only be considered as an option for people who have not had noticeable improvements in their dizziness after long-term drug and rehabilitation treatments.

People with dizziness associated with ear discharge, long-standing middle ear infections, or ear drum perforations are the group most likely to be considered for surgery.