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Dizziness and balance problems
A guide for patients and carers
What treatments are available?
Although many causes of dizziness, such as viral labyrinthitis, BPPV, post-traumatic and non-specific peripheral vestibular disorders, tend to recover on their own, if you have been referred to a hospital consultant it is quite possible that the dizziness has not cleared up of its own accord in your case. If this is the case then do not despair! You are also likely to do well in the long term. The mainstay of treatment, common to almost all the conditions mentioned above, is vestibular rehabilitation.
Vestibular rehabilitation
It has been shown that if the vestibular system is damaged, a number of mechanisms operate in the brain which tend to improve the functioning of the balance system. As explained earlier, most symptoms of dizziness and vertigo appear as a result of an imbalance between the functioning of the right and left vestibular organs in the inner ear. The processes, which tend to correct this imbalance are known as “vestibular compensation”. This compensation can be achieved even when the damage to the inner ear is permanent. In essence, vestibular compensation relies on your brain learning to cope with the disorientating signals coming from the inner ears and learning to use alternative signals from your eyes, ankles, legs and neck to keep you balanced. As a result, the tendency to fall or veer to one side, the jerky eye movements (nystagmus) and the dizziness gradually disappear.
One way of helping the development of vestibular compensation is by doing so-called vestibular exercises. These exercises involve movements of the eyes, the head, the trunk and finally the whole body under different visual conditions (e.g. with the eyes open and then closed, while looking at steady objects or at a moving ball). A point that cannot be stressed too much is that in order for the brain to put into place the mechanisms of vestibular compensation, it has to sense that imbalance or dizziness are present. For example, if you are taking regular anti-vertiginous drugs or are lying absolutely still in bed, you do not experience any dizziness. If the brain does not sense any dizziness or imbalance it will not realise that something is wrong. For this reason, the physiotherapist or other professional in charge of your rehabilitation may ask you that, in agreement with your doctor, you reduce and eventually stop your anti-vertiginous medication.
As you progress to the more difficult exercises of the rehabilitation programme you may experience dizziness. This should not be interpreted as a “red flag” to stop the exercises - quite the contrary. What this means is that an imbalance between your left and right vestibular systems still exists, and the exercises you are doing will help your brain to detect this imbalance and then gradually put it right. You should not go to the extreme of trying to induce dizziness by moving or exercising to such an extent that you are sick or become exhausted. If the surgery you attend is not familiar with vestibular exercises (sometimes called Cawthorne Cooksey or balance exercises), some of the organisations listed at the end of this booklet might be able to help.
Particle repositioning procedures
As mentioned above under BPPV (Benign Paroxysmal Positional Vertigo), this is now the treatment of choice for this condition. Although most cases of BPPV will sort themselves out within a few weeks to a few months, these repositioning procedures can bring about a rapid recovery in one or two sessions. People who have recurrences of BPPV can either have the repositioning procedure repeated or they can be shown exercises (e.g. Brandt-Daroff exercises) which they can do at home. Again, if your doctor is not entirely familiar with these procedures you can find out about them from some of the organisations listed at the end of this booklet or from regional physiotherapy or audiology centres.
Anti-vertiginous drugs
A variety of drugs are available that can make you feel better during the initial or severe phases of many vestibular disorders. These tablets, however, should only be reserved for the first few days of an attack of dizziness because, as mentioned above, long-term improvement depends on vestibular compensation, not tablets. The same applies to tranquillizers, as the risks of addiction and their interference with the development of vestibular compensation usually outweigh their possible benefits in reducing anxiety.
Counselling, relaxation therapy, breathing exercises
If you have suffered from dizziness for a long period of time you may be concerned that it will never go away, or that, in spite of what doctors tell you, there may be something seriously wrong with you. You may be worried that you are not able to look after your children properly, or you may be worried about going to work or attending social events for fear of embarrassment. In some cases what was initially thought to be a vestibular disorder may have actually been brought on by stress, fear or tension.
The distinction is not always easy. For instance, some people with balance disorders suffer increased bouts of dizziness in crowds and shopping centres, or whilst driving or looking at moving images on TV or at the cinema. This occurs because their moving surroundings confuse their balance centres. However, some people who have a fear of public places or who experience panic attacks - but who have an intact balance system - also report symptoms of dizziness and unsteadiness. Sometimes this is the result of excessive breathing, or hyperventilation. People with vestibular problems will usually benefit from being reassured about the non-sinister nature of the disorder, and this together with spontaneous or rehabilitation-induced vestibular compensation will gradually reduce their feelings of anxiety. In some cases, counselling, relaxation or breathing exercises help people to feel more in control of the situation and can also cut down the episodes of dizziness which are brought on by tension or hyperventilation.
Surgery
Only a very small minority of people with dizziness have to undergo surgery to see any improvement in their symptoms. The type of operation they will undergo will vary according to the individual preferences of the ear surgeon. Surgery will only be considered if long term use of drugs and rehabilitation treatments have failed to bring about a noticeable improvement. Surgery is a more likely option for people whose dizziness is associated with ear discharge, long-standing middle ear infections or ear drum perforations.
It has been shown that if the vestibular system is damaged, a number of mechanisms operate in the brain which tend to improve the functioning of the balance system. As explained earlier, most symptoms of dizziness and vertigo appear as a result of an imbalance between the functioning of the right and left vestibular organs in the inner ear. The processes, which tend to correct this imbalance are known as “vestibular compensation”. This compensation can be achieved even when the damage to the inner ear is permanent. In essence, vestibular compensation relies on your brain learning to cope with the disorientating signals coming from the inner ears and learning to use alternative signals from your eyes, ankles, legs and neck to keep you balanced. As a result, the tendency to fall or veer to one side, the jerky eye movements (nystagmus) and the dizziness gradually disappear.
One way of helping the development of vestibular compensation is by doing so-called vestibular exercises. These exercises involve movements of the eyes, the head, the trunk and finally the whole body under different visual conditions (e.g. with the eyes open and then closed, while looking at steady objects or at a moving ball). A point that cannot be stressed too much is that in order for the brain to put into place the mechanisms of vestibular compensation, it has to sense that imbalance or dizziness are present. For example, if you are taking regular anti-vertiginous drugs or are lying absolutely still in bed, you do not experience any dizziness. If the brain does not sense any dizziness or imbalance it will not realise that something is wrong. For this reason, the physiotherapist or other professional in charge of your rehabilitation may ask you that, in agreement with your doctor, you reduce and eventually stop your anti-vertiginous medication.
As you progress to the more difficult exercises of the rehabilitation programme you may experience dizziness. This should not be interpreted as a “red flag” to stop the exercises - quite the contrary. What this means is that an imbalance between your left and right vestibular systems still exists, and the exercises you are doing will help your brain to detect this imbalance and then gradually put it right. You should not go to the extreme of trying to induce dizziness by moving or exercising to such an extent that you are sick or become exhausted. If the surgery you attend is not familiar with vestibular exercises (sometimes called Cawthorne Cooksey or balance exercises), some of the organisations listed at the end of this booklet might be able to help.
Particle repositioning procedures
As mentioned above under BPPV (Benign Paroxysmal Positional Vertigo), this is now the treatment of choice for this condition. Although most cases of BPPV will sort themselves out within a few weeks to a few months, these repositioning procedures can bring about a rapid recovery in one or two sessions. People who have recurrences of BPPV can either have the repositioning procedure repeated or they can be shown exercises (e.g. Brandt-Daroff exercises) which they can do at home. Again, if your doctor is not entirely familiar with these procedures you can find out about them from some of the organisations listed at the end of this booklet or from regional physiotherapy or audiology centres.
Anti-vertiginous drugs
A variety of drugs are available that can make you feel better during the initial or severe phases of many vestibular disorders. These tablets, however, should only be reserved for the first few days of an attack of dizziness because, as mentioned above, long-term improvement depends on vestibular compensation, not tablets. The same applies to tranquillizers, as the risks of addiction and their interference with the development of vestibular compensation usually outweigh their possible benefits in reducing anxiety.
Counselling, relaxation therapy, breathing exercises
If you have suffered from dizziness for a long period of time you may be concerned that it will never go away, or that, in spite of what doctors tell you, there may be something seriously wrong with you. You may be worried that you are not able to look after your children properly, or you may be worried about going to work or attending social events for fear of embarrassment. In some cases what was initially thought to be a vestibular disorder may have actually been brought on by stress, fear or tension.
The distinction is not always easy. For instance, some people with balance disorders suffer increased bouts of dizziness in crowds and shopping centres, or whilst driving or looking at moving images on TV or at the cinema. This occurs because their moving surroundings confuse their balance centres. However, some people who have a fear of public places or who experience panic attacks - but who have an intact balance system - also report symptoms of dizziness and unsteadiness. Sometimes this is the result of excessive breathing, or hyperventilation. People with vestibular problems will usually benefit from being reassured about the non-sinister nature of the disorder, and this together with spontaneous or rehabilitation-induced vestibular compensation will gradually reduce their feelings of anxiety. In some cases, counselling, relaxation or breathing exercises help people to feel more in control of the situation and can also cut down the episodes of dizziness which are brought on by tension or hyperventilation.
Surgery
Only a very small minority of people with dizziness have to undergo surgery to see any improvement in their symptoms. The type of operation they will undergo will vary according to the individual preferences of the ear surgeon. Surgery will only be considered if long term use of drugs and rehabilitation treatments have failed to bring about a noticeable improvement. Surgery is a more likely option for people whose dizziness is associated with ear discharge, long-standing middle ear infections or ear drum perforations.
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