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.