The Balance System
Physiologically, balance is the ability to maintain the centre of gravity of the body within its base of support with minimal postural sway. It functions both at rest and during movement of the body. It has been referred to as the sixth sense.
Sensation of balance
Normal balance is generally subconscious and we only have full cortical awareness when balance is lost. This loss of balance is very disturbing to the individual as it consists of unusual sensations. This disturbance is generally accompanied by fear and panic with the secondary autonomic effects of nausea and vomiting.
Basic physiology of balance
To maintain normal balance the brain requires both complex sensory input and then needs to initiate well coordinated motor or muscle activity to maintain normal postural control.
The sensory inputs provide details of changes in the body’s position within itself and in relation to the environment. These sensory inputs are derived from: normal vision, normal vestibular inputs and normal somatosensory feedback.
Benign Paroxysmal Positional Vertigo (BPPV)
Benign Paroxysmal Positional Vertigo (BPPV) is a disorder of the inner ear, which can occur after an injury, or virus, with disease or spontaneously. It characteristically presents with short and intense bouts of vertigo (spinning sensations), which are related to certain changes of position (e.g. lying down, leaning forwards or rolling over in bed).
It is caused by small particles of calcium carbonate (otoconia) which may dislodge and float freely within the canals of the inner ear. Symptoms may resolve spontaneously or they may benefit from assessment and treatment by the clinician.
This would normally involve some testing positions to assess the affected ear and re-positioning manoeuvres to treat the affected ear.
The inner ear is made up of very small and delicate balance and hearing apparatus.
Labyrinthitis is an infection or inflammation of the inner ear. The labyrinth provides us with sensory information about motion and assists the vision with gaze stability. Labyrinthitis can cause acute vertigo and hearing loss.
Vestibular Neuritis is an inflammation (usually viral) of the vestibular nerve. It can cause severe vertigo, nausea and vomiting due to the affected nerve not transmitting the appropriate sensory information from the inner ear to the brain.
Whilst the symptoms of vertigo and nausea can be severe initially, they usually lessen after several days. Some symptoms may persist with a graded return to normal activity. Medical management and correct diagnosis is highly recommended at the onset.
Referral to the Wellington Dizziness and Balance Service Physiotherapist for assessment and a customised rehabilitation programme, may also be recommended to assist with a return to normal activities.
Bilateral Vestibular Loss
Bilateral Vestibular Loss, or Hypofunction, is a vestibular problem involving both inner ears. Symptoms of imbalance and visual disturbance (oscillopsia) are the main features. It is a rare condition and most often caused by ototoxicity. Antibiotics, such Gentamycin, can be ototoxic and can give rise to a bilateral lesion, although some bilateral vestibular problems are caused by viral infections or tumour or sometimes due to sensory changes with age.
Vestibular assessment and rehabilitation by a physiotherapist can be very useful in this condition.
Acoustic Neuroma or Vestibular Schwannoma is a benign tumour of the brain that can affect the Vestibulo-cochlea nerve (8th cranial nerve). They are rare and often very slow growing but can cause significant balance and hearing problems as well as problems with the muscles of the face. Medical advice is recommended for specific investigations and management.
Perilymphatic Fistula (PLF)
A fistula is an opening or connection which is abnormal. The condition Perilymphatic Fistula (PLF) is an opening between the middle ear (air filled) and inner ear (fluid filled). A Perilymphatic fistula may also be present between the bone surrounding the inner ear and the brain, allowing fluid to communicate. Perilymphatic fistula is rare and symptoms may be induced by pressure changes caused during coughing, sneezing or blowing the nose. Symptoms may also be provoked by noise.
Prompt medical advice is recommended for accurate diagnosis and specific treatment.
Semicircular canal dehiscence (SCD)
Semicircular canal dehiscence (SCD) is a rare and still relatively unknown condition, caused from an opening (dehiscence) within the bony shell of the superior semicircular canal. Semicircular canal dehiscence can affect both hearing and balance to varying extents in individuals.
A referral to the Wellington Dizziness and Balance Service will enable a thorough investigation into your symptoms, completing all imaging and assessments. Onward referrals for surgical intervention and any rehabilitation will be facilitated as indicated.
Meniere’s disease is a disorder of the inner ear which is characterized by episodes of acute vertigo, tinnitus, hearing loss and aural fullness (pressure in the ear). The most prominent feature of Meniere’s disease is vertigo and associated nausea, and vomiting. Other symptoms such as hearing loss or tinnitus are often noted later.
Meniere’s disease usually affects only one ear initially but can eventually affect both ears. The disease process is progressive with unpredictable attacks, but symptoms usually resolve following an attack. In the late stages of Meniere’s disease, hearing loss is often more permanent, as repeated pressure may cause irreversible damage to the inner ear structures.
Medical advice should be sought for diagnosis and management. Your consultant may request you have special tests which may include a hearing test, vestibular function tests, blood tests or an MRI. Your Consultant will advise you on what course of treatment is best for you.
Migraine affects approximately 15% of the UK population, typically between 20 and 50 years old. There are two main types of migraine; Migraine without aura (previously known as Common Migraine) and Migraine with aura (previously known as Classic Migraine).
Vestibular migraine is a term used to describe a headache with vertigo presenting at some time before, during or after the headache phase.
Treatment of Vestibular Migraine is the same as with Migraine with/without aura – specifically reduction of risk factors and prescription of either prophylactic medications other medications.
It is strongly recommended that medical advice is sought, as some symptoms may be due to causes other than migraine. A referral to the Wellington Dizziness and Balance Service will enable accurate diagnosis and management of any associated rehabilitation needs.
Balance problems following Traumatic Brain Injury
Traumatic Brain Injury (TBI) can cause a multitude of physical, sensory and cognitive problems that can all impact on an individual’s balance, mobility and independence. Specialist Neurological Rehabilitation typically manages this population. However, specific vestibular pathologies can also occur as a result of the TBI and can have an additional impact on regaining efficient balance, postural control and functional independence.
There are many conditions that may present themselves affecting the vestibular system, the vestibular nerve or areas of the brain such as the cortex or cerebellum. The main causes of these conditions are inner ear concussion, temporal bone fractures and central haemorrhage or contusions. In addition to these causes, cervical trauma or ‘whiplash’ and psychological factors may be involved.
Within this population, the recognition of both peripheral and central causes of dizziness and balance problems is essential. Other injuries or factors such as, pain and joint restrictions, or cognitive and behavioural problems, may complicate the rehabilitation process. As a result of all these co-existing features from the TBI, recovery of any peripheral symptom is likely to take significantly longer with a prolonged rehabilitation period.
Balance problems with Multiple Sclerosis
Multiple Sclerosis (MS) is an autoimmune condition, meaning your own immune system attacks your own body’s tissue by mistaking it for a foreign body. Within MS, the tissue that is attacked is the protective cover on nerves (myelin sheath) within the central nervous system. This damage to the myelin causes the messages travelling down the nerves to be stopped, slowed down or interfered with. In addition to the myelin damage, the nerves themselves can be damaged, which leads to disability over time.
Balance requires messages to travel up to the brain, be integrated and a message be sent out from the brain to the body to react or move. If the input messages are affected, this will provide unreliable information regarding the body’s position and balance.
Common symptoms of MS may include visual disturbance, altered sensation and vertigo and dizziness. Assessing these symptoms will enable accurate management of any coincidental peripheral vestibular pathology. Rehabilitation requires an holistic approach to manage all potential causes for balance problems and address underlying postural control and substitution strategies.
Concussion is a mild traumatic brain injury which occurs after sustaining an injury to the head through an accident or an object forcefully coming into contact with the head. It may or may not be accompanied by a loss of consciousness. The concussion may disrupt the brain’s ability to process sensory information.
Concussion symptoms may impact physical, emotional and mental well-being, including cognitive problems. Physical symptoms may include: dizziness; headache; imbalance; incoordination; nausea/vomiting; fatigue; sleep disturbances; double or blurred vision; and sensitivity to light and sounds. Common emotional symptoms may include: irritability; restlessness; anxiety; depression; mood swings; aggression or reduced tolerance to stress. Other symptoms may affect cognitive function and the ability to think and process information. These may include: difficulty with memory; confusion; slowed processing; “fogginess”; and reduced concentration.
If you are experiencing dizziness or balance problems following a concussion injury, assessment by a Vestibular Physiotherapist can identify if and how much the vestibular system has been affected by the injury. Vestibular and balance rehabilitation therapy (VBRT) assists with your body’s recovery from the concussion and helps you to reach your goals and return to your normal level of physical abilities, sports and hobbies.
If you are experiencing difficulties with memory, attention, and concentration or generally slower processing times, it may be useful to be assessed and managed by a Neuropsychologist. They may be helpful for managing changes in mood, anxiety, irritability, personality or behaviour following a concussion. They can monitor your symptoms and advise on strategies to improve these symptoms, which will benefit your recovery and return to your usual daily life and work.
Age related balance problems
Age-related changes to the sensory and musculoskeletal systems of the body may have significant effects to balance and mobility for the ageing person. These include delayed reaction times and reduced sensory acuity.
Staying active is an important part of being healthy as we age. If you are having problems with your balance, it could be useful explore the expert advice available at the Wellington Dizziness and Balance Service. It is important to remember age is not a factor in recovery from peripheral vestibular injury.
Management of Dizziness and Balance Disorders
The first step in management of dizziness and balance disorders is to establish the reasons for the disordered function. This requires a very detailed history from the patient with a full description of the symptoms suffered by the patient. It is accompanied by a detailed clinical examination of all the systems involved in balance using more specific tests and investigations.
Once a working diagnosis is formed, a treatment programme can be devised. This will involve the medical treatment of any specific disease causing the problem, as well as a programme of rehabilitation to restore balance function.
Why is the Wellington Dizziness and Balance Service different?
The Wellington Dizziness and Balance Service is composed of ENT surgeons, audiologists and physiotherapists involved in dizziness and balance problems, and offers comprehensive analysis and rehabilitation services. Our unique specialised and comprehensive service brings together the clinicians to manage dizziness and balance problems.
The physiotherapists working in the Wellington Dizziness and Balance Service have special expertise and extensive experience in the area of Vestibular and Balance Rehabilitation, which is a key component to recovery once diagnosis is identified.
Vestibular and Balance Rehabilitation
Vestibular and balance rehabilitation has developed through recent years and the treatment provided will often be customised and multi-faceted to suit the condition that is being managed. The programme will address the dizziness, the efficiency of the balance strategies in the body and the plasticity of the central nervous system.
Physiotherapists at The Wellington Hospital are trained to perform Canal Repositioning Treatments and Liberatory manoeuvres to treat BPPV as indicated.
Other treatments such as gait re-education, general balance, relaxation and muscle strengthening can be incorporated. Strategies and advice will be discussed i.e. safety issues and functional goals will be set and reviewed with the patient.
Individual home exercise programmes will be designed for each patient and reviewed as appropriate. Treatment duration will be dictated by the reviewing of goals and performance on outcome measures.
Audiological and Vestibular Function Testing
The Wellington Dizziness and Balance Service offers a full range of diagnostic vestibular test procedures with easy-to-understand patient information provided prior to the appointment.
Some of the tests provided include:
We provide a full range of audiological test procedures, such as pure tone audiometry, tympanometry, acoustic reflexes and tinnitus measurements. This is done in a soundproof environment.
Oculomotor Testing using Video-Nystagmography (VNG)
This includes gaze testing, smooth pursuit tracking and optokinetic testing. The VNG is a visual measurement of the movement of the eyes. This involves a light moving across a display screen in a darkened room and the patient will be required to follow the light with their eyes.
During this test a small probe is placed at the entrance of the ear. Through this probe, warm and cool water/air is introduced into the ear canal which stimulates a response from the balance system. Eye movements are then monitored to test this response and provide valuable diagnostic information.
A Physiotherapy assessment starts with taking a thorough subjective history and often this is aided by questionnaires sent out prior to the initial appointment. Through a structured and systematic approach, a thorough assessment can provide a basis for diagnosis and guide further physical assessment and subsequent management.
Following the assessment, a customised rehabilitation treatment plan will be provided. Any necessary onward referrals that are identified, such as psychology, will be discussed with the referrer as well as any other specific management. Some patients may require further musculoskeletal assessment and treatment.
At The Wellington Balance Centre, the physiotherapists are specially trained in vestibular assessment and rehabilitation.
The physiotherapists conduct an in depth assessment which may include Posturography using the Smart EquiTest Computerised Dynamic Posturography system. This is a state-of-the-art computer and force plate system that is able to detect problems in any part of the balance system. The Smart EquiTest system can be used for treatment of balance disorders.
We offer customised vestibular rehabilitation programs tailored specifically to each individual's needs. Our therapists use current evidence based practice and the latest in rehabilitation techniques
Computerised Dynamic Posturography
Computerised Dynamic Posturography (CDP) (SMART EquiTest ) is an assessment tool used by the Physiotherapist to objectively quantify balance control. A force plate is used to analyze movement patterns. A safety support vest is worn during testing and the CDP exposes the patient to a variety of controlled visual and support surface conditions. It is designed to compliment clinical testing and categorize pathological mechanisms of balance disorders. CDP can identify and differentiate the functional impairments associated with the pathological processes but CDP alone cannot diagnose specific pathology or site-of-lesion.
During CDP assessment the patient is presented with a variety of conditions specifically ordered to examine adaptive mechanisms and selection processing of sensory information and movement response patterns.
Because of the complex interactions among sensory, motor, and central adapting processes, CDP requires separate protocols to adequately differentiate among impairments. To quantify the failure of adaptive mechanisms to select appropriate sensory inputs and movement response patterns, CDP exposes the patient to a variety of controlled visual and support surface conditions.
The SMART EquiTest posturography system used at The Wellington Balance Centre, allows targeted rehabilitation to a high level with focus specifically on the use of visual, vestibular and somatosensory cues for balance. Its treatment capabilities allow a graded programme and degree of difficulty, using visual feedback coupled with sensitive monitoring of patient movement on a force platform.