UNDERSTANDING VERTIGO and Balance disorders
The human balance system receives input from three different sources
1.Vision - Information with respect to external objects around us.
2. Somatosensory cues- Information with respect to the body (ie, information from muscles, joints about their exact position; touch and pain sensations from the skin). All the information is taken by the nerves through the spinal cord to the brain. Brain processes this information to get an idea or a map of our body in space.
3. Vestibular system - Provides 3D representation of head and body movements in space.
Vestibular apparatus senses the motion and sends information through the nerves to higher brain centres for further detailed processing.
These 3 sets of inputs are integrated in the Brain. They are combined and compared with each other. The end result is Space concept / spacial orientation.
When we are lying / sitting/standing / walking at ‘any given place’, body would have calculated expected responses from the 3 organ systems, learned from the past experiences (stored information). As long as the sensory inputs from three organ systems match with the previously stored information, balance is maintained. Mismatch results in vertigo and other disturbances of balance.
Vertigo and dizziness are common conditions among older adults. They are closely associated with fall risk and portend major implications for geriatric injury and disability. Balance problems can make you feel dizzy, as if the room is spinning, unsteady, or lightheaded. You might feel as if the room is spinning or you're going to fall down. These feelings can happen whether you're lying down, sitting or standing. And the chance of having a balance problem, study results showed, increases with age and diabetes. Eighty-five percent of men and women over age 80 had an imbalance problem, 23 times more than people in their 40s and people with diabetes were 70 percent more likely to suffer from balance problems. Researchers say this is likely due to damage done by high blood sugar levels to the hair cells in the inner ear that facilitate balance control and to the long-term damage from diabetes to the inner ear’s small blood vessels.
Signs and symptoms of balance problems include:
· Sense of motion or spinning (vertigo)
· Feeling of faintness or lightheadedness (presyncope)
· Loss of balance or unsteadiness
· Falling or feeling like you might fall
· Feeling a floating sensation or dizziness
· Vision changes, such as blurriness
Symptoms of balance disorders are perplexing for the patient, owing to lack of awareness, the patients are not able to explain the exact feeling in words.
For example, these are the words commonly used by patients to describe balance disorder(s): vertigo, dizziness, giddiness, light headedness, discomfort in the head, motion sickness, rocking feel, postural instability or swaying while walking, fear of fall while standing or walking, syncope, loss of consciousness.
Many medical conditions can cause balance problems. However, most balance problems result from issues in your balance organ in the inner ear (vestibular system).Vestibular imbalances need to be taken seriously because falls can be fatal and injuries can be painful, lead to long hospital stays and result in significant loss in quality of life.
Now that the magnitude of balance problems is established, primary care physicians are more likely to be on the look out for its early signs and symptoms, and more attuned to when a patient needs to be referred to a balance disorders specialist.
People with vestibular dysfunction can take preventive steps to avoid falls in their homes, such as installing guard rails along stairs or hallways where a fall might occur, making sure rooms are well lit, and removing carpeting in places where people are more prone to trip.
One-third between the ages of 65 and 75 report that dizziness or unsteadiness is a major concern that diminishes their quality of life. Fortunately, it can often be treated.
All types of dizziness, and especially vertigo, can contribute to falls in seniors. It is important to know that dizziness, vertigo, and imbalance are not a normal part of aging, and that treatment is available. Older people do not need to live in fear of falling.
We have to assess Duration, Onset, Progression, Continuous / Episodic, Frequency, Quality, Timing and Triggers. Attention to detail is important. Specific triggers needs to be noted - Positional - especially while lying down or turning in bed, Orthostatic, Post prandial, Before next meal intake, Tulio phenomenon, Visual stimuli (Visual dependence), Eating habits- meniers, migraine, Travel, sleep related, exposure to bright lights, odour, Seasonal - meniers, migraine, Catemenial, Specific situational aggravation.
Targeted leading questions needs be asked - Oscilopsia, Headache, Aura, Subtle symptoms of Parkinsonism, Autonomic system involvement, Peripheral nerve involvement, Sensory ataxia, Stance & Posture.
Associated symptoms to be looked are - Tinnitus, hard of hearing, Vomiting, Anxiety, fear, tremulousness of limbs, Stress, Diaphoresis, palpitation, Chest pain, Breathlessness, Weakness of limbs,inco-ordination of limbs, Slurred speech, Blurred vision, Amorosis fugax, Diplopia, Oscilopsia, ptosis, Numbness / loss of sensation in the face or hemisensory diminution, Facial lag or deviation, difficulty in marshalling food inside the mouth, Hiccoughs, Difficulty in swallowing, nasal regurgitation.Never miss asking for Head trauma. Recent fever, medication history.
Examination confirms the hypothesis put forth after history.
General examination - look for Pallor, Blood pressure - orthostatic drop, both arms, Pulse- rate, rhythm, Bruit.
Ophthalmic examination- Visual acuity - Static & Dynamic, Visual fields, Pupil- especially Horners syndrome, Fundus
Evaluate eye movements for Alignment, Full range of motion, Saccade- latency, accuracy & velocity, Smoothness of pursuits, Fixation, Convergence.
Look for nystagmus - Spontaneous, Gaze evoked, Positional, Provoked - Head shaking Nystagmus, Vibration of the mastoid, Valsalva maneuver, Hyperventilation.
Look for Skew deviation- Vertical misalignment of the eye. Implies a central pathology. Do Cover-uncover test.
Assessment of Vestibulo-occular reflexes - Head impulse test, Dynamic visual acuity, Caloric responses.
Assessment of Vestibulospinal reflexes- Past pointing, Romberg, Tandem walking test (with eyes open and then closed) , Star walking test, Fukuda stepping test.
Look for Incoordination- Finger-nose-Finger, Knee-Heel test, Other cerebellar signs.
Examine Gait (walk) & Posture- Gait initiation, width of the base, asymmetry of toe lift, shortened stride length, Excessive movement of the hips, arm swing, Tandem walking (eyes open and closed)
Sensory examination, specifically peripheral nerves - DTR's, Nerve thickening, Altered sensation (pain /touch /temperature / vibration / joint position)
Specific tests for BPPV - Dix halpikes test.
From the important history - Timing, Triggers, Targeted Examination - we group the patients symptoms in to - Episodic vestibular syndromes, Acute vestibular syndromes, chronic vestibular syndromes.
Accordingly the symptoms are categorised in one of three syndrome patterns based on history and examination
1.Acute vestibular syndrome — comprising of acute onset of vertigo or dizziness, or unsteadiness which could last from days to weeks. The symptoms could be aggravated by head movement and be associated with nausea, vomiting and nystagmus. The differential diagnosis includes : vestibular neuritis , stroke, drug toxicity, demyelinating disease
2. Episodic vestibular syndrome — characterised by recurrent episodes of vertigo or dizziness or unsteadiness lasting seconds to hours and rarely even days as seen with vestibular migraine, Ménière disease, TIA, vestibular paroxysmia.
3. Chronic dizziness/ unsteadiness - b/l vestibular failure, neurological gait disorders, psychogenic.The common presentations are BBPV, vestibular migraine, Vestibular neuritis, PPPD, Parkinsonism, Stroke, severe peripheral neuropathy (usually diabetic), bilateral Vestibulopathy, Orthostatic dizziness, drug induced dizziness etc .
INVESTIGATION1.Functional integrity testing - VEMP, ENG, VOG, SVV, V-HIT, Gait analysis, posturography, PT-Audiometry. 2.Structural integrity testing - Imaging studies (MRI) 3.Hb, PCV, Blood sugar, Lipid profile, Cardiac work-up, When indicated- NCS, EEG TREATMENT Treating the cause results in good recovery. 1.Pharmacotherapy- It aims at suppressing the acute vestibular symptoms (vertigo, instability, nausea, vomiting), as well as disease specific treatment for the causative factor.
2.Vestibular Rehabilitation Therapy- The human vestibular system is versatile and highly adaptive, which has inherent mechanisms to detect errors in performance and also to correct them, in case of a problem. The VR therapies optimises the usage of inputs from the ‘remaining’ vestibular function, visual and somatosensory cues.
3.Adjunctive therapy- cognitive behavioural therapy, relaxation techniques, breathing exercises, environmental modifications and safety measures.
4.In the acute stages- controlling symptoms and is especially useful in relieving autonomic features like nausea and vomiting.
5.Acute episodes of vertigo are managed with vestibular suppressants and anti-emetics, Vestibular suppressants are used only for a shorter duration as prolonged use affects the natural compensatory mechanism.
6.Medications used for acute attacks
7. Vestibular Rehabilitation Therapy. Human vestibular system is versatile and highly adaptive. There are inherent mechanisms to detect errors in performance and also to correct them, with normal development, aging as well as in case of a disease process. VRT's take advantage of the innate plasticity of the balance system and speed up the natural compensation process. In a patient with vestibular lesion, optimising the usage of inputs from the "remaining" vestibular function, visual and somatosensory cues forms the crux of VRT.
TIPS to prevent falling
For elders who want to continue living independently, home safety is essential.
1. Installing a grab bar in bathrooms with a blind fastening system or with blocking in the wall.
2. Non slip bath mats in bathrooms and other floor surfaces.
3. Lightening the room with bright lights so that they see well.
4. Railings on both sides of the stairs.
5. Medical alert systems can be installed near the bed side for them to call in emergency.