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Dizziness in TBI

  Home   |   Dizziness in TBI
Dizziness

Dizziness is a non-specific term used to describe a range of sensations that can make a person feel unsteady, lightheaded, faint, or as if they or their surroundings are spinning or moving. It is a common symptom that can result from various underlying causes, including issues with the inner ear, neurological conditions, cardiovascular problems, medication side effects, dehydration, anxiety, and more.

There are different types of dizziness, including:

  • Vertigo: This type of dizziness gives a person the sensation that they or their surroundings are spinning or moving, even when standing still. It often occurs due to problems with the inner ear or the vestibular system, which is responsible for maintaining balance.

  • Presyncope: Presyncope refers to feeling faint or lightheaded without actually losing consciousness. It can result from a temporary decrease in blood flow to the brain, such as when standing up too quickly (orthostatic or postural hypotension).

  • Disequilibrium: Disequilibrium is a feeling of unsteadiness or imbalance, as if the person is going to fall. It can stem from issues with proprioception (awareness of body position) or problems with the vestibular system.

  • Lightheadedness: Dizziness that does not fall into the categories of vertigo, presyncope, or disequilibrium is often classified as lightheadedness, which can manifest as feelings of floating, disorientation, or difficulty concentrating.

Dizziness can be accompanied by additional symptoms such as nausea, vomiting, sweating, ringing in the ears (tinnitus), headache, or visual disturbances. Given the wide range of potential causes, it is important for a person to consult a suitably trained healthcare professional, as a proper diagnosis is crucial for determining the underlying cause and appropriate treatment.

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How common is dizziness in TBI?

Dizziness is a common symptom following brain injuries and can persist for varying durations. The prevalence of dizziness in brain injuries, including traumatic brain injuries (TBIs), varies depending on the severity and type of injury, as well as other contributing factors.

Here are some insights into the prevalence of dizziness in brain injuries:

  • Traumatic Brain Injuries (TBIs): Dizziness is a frequent complaint following TBIs, including concussions. Studies have shown that dizziness is among the most common symptoms experienced by individuals with TBIs. The prevalence of dizziness in these individuals can range widely, from approximately 30% to over 70%, depending on the study population and criteria used for assessment.

  • Mild Traumatic Brain Injuries: Dizziness is a hallmark symptom of mild TBIs, commonly known as concussions. Research indicates that dizziness occurs in a significant proportion of individuals who sustain concussions, with estimates ranging from 30% to 90% in various studies.

  • Moderate to Severe Traumatic Brain Injuries: Dizziness is also prevalent in individuals with moderate to severe TBIs. While severe TBIs may be associated with a higher risk of dizziness due to more extensive brain damage, dizziness can occur across the entire spectrum of TBI severity.

  • Post-Concussion Syndrome (PCS): In some individuals, dizziness can persist beyond the acute phase of injury, leading to post-concussion syndrome (PCS). PCS is characterized by the persistence of symptoms such as dizziness, headaches, fatigue, and cognitive difficulties for weeks or even months after the initial injury.

  • Other Types of Brain Injuries: Dizziness can also occur in other types of brain injuries, such as hemorrhages, strokes, or tumors, depending on the location and extent of the brain damage


  2. Smith RM, Burgess C, Tahtis V, et al
    Why are patients with acute traumatic brain injury not routinely assessed or treated for vestibular dysfunction in the UK? 
    A qualitative study 
    BMJ Open 2023;13:e067967. doi: 10.1136/bmjopen-2022-067967

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Impacts of Dizziness in TBI

Dizziness can have profound consequences for TBI patients, affecting their physical, emotional, and social well-being. The impact varies based on the severity, frequency, and underlying causes of dizziness. Key consequences include:

  • Increased Risk of Falls: Dizziness impairs balance, heightening the risk of falls and injuries such as fractures, sprains, or further head trauma—especially concerning for TBI patients.

  • Functional Impairment: Persistent dizziness can disrupt daily activities, work, and recreation, leading to a reduced quality of life. TBI patients may struggle with driving, working, or engaging in social activities.

  • Anxiety and Depression: Chronic dizziness often leads to anxiety, depression, and social isolation. The unpredictability of symptoms can cause heightened anxiety about experiencing dizziness in public or during activities.

  • Difficulty Concentrating: Dizziness can impair cognitive function, making it hard to focus during cognitive therapy or tasks requiring mental effort. This can slow progress in cognitive rehabilitation, affecting memory, attention, and problem-solving skills.

  • Increased Fatigue: Dizziness is physically and mentally exhausting, leading to quicker fatigue during therapy sessions. This may result in shorter sessions, reduced exercise intensity, and less overall therapeutic benefit.

  • Decreased Independence: Dizziness can diminish a TBI patient's sense of independence, leading to reliance on others or adaptive devices. This loss of independence can have significant emotional and psychological impacts.

  • Impact on Relationships: Dizziness can strain relationships with family, friends, and caregivers, particularly if ongoing support is needed. Caregivers may also experience increased stress and burden.

  • Poor Engagement with Therapies: Dizziness can create significant barriers to fully participating in therapy activities, potentially delaying recovery and reducing the effectiveness of rehabilitation.

  • Work and Financial Challenges: Dizziness may hinder a TBI patient’s ability to work, leading to financial strain and career disruption, with long-term consequences for financial stability.

  • Avoidance of Activities: TBI patients may avoid activities or environments that trigger dizziness, resulting in decreased participation in meaningful activities and potential social withdrawal.

Kleffelgård, Ingerid & Langhammer, Birgitta & Hellstrom, Torgeir & Sandhaug, Maria & Tamber, Anne-Lise & Søberg, Helene. (2017). Dizziness-related disability following mild–moderate traumatic brain injury. Brain Injury. 31. 1-9. 10.1080/02699052.2017.1377348. 
Hartvigsen J, Boyle E, Cassidy JD, Carroll LJ. Mild traumatic brain injury after motor vehicle collisions: what are the symptoms and who treats them? A population-based 1-year inception cohort study. Arch Phys Med Rehabil. 2014;95:S286–94. doi:10.1016/j. apmr.2013.07.029.
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Vestibular Conditions in TBI

Traumatic Brain Injury (TBI) can lead to a range of vestibular conditions, significantly impacting a patient’s balance, spatial orientation, and overall quality of life. The balance system, which includes the vestibular system, vision, proprioception, brainstem, and cerebellum, is often compromised in TBI, resulting in various debilitating symptoms.

Common Vestibular Conditions Associated with TBI

  • Benign Paroxysmal Positional Vertigo (BPPV): One of the most common vestibular disorders following TBI, BPPV occurs when tiny calcium crystals in the inner ear become dislodged and enter the semicircular canals, causing vertigo. BPPV leads to sudden episodes of dizziness or spinning, particularly when changing head positions, such as looking up, lying down, or turning over in bed.

  • Post-Traumatic Meniere’s Disease: This condition may develop after TBI and is characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and a sensation of fullness in the ear.

  • Labyrinthine Concussion: Trauma to the inner ear or vestibular nerve can result in a labyrinthine concussion, causing acute vertigo, hearing loss, tinnitus, and imbalance, often occurring immediately after the injury.

  • Vestibular Nerve Concussion: Trauma to the VIIIth cranial nerve can lead to dizziness, vertigo, and unsteadiness. In some cases, this can affect both sides, causing bilateral vestibular hypofunction.

  • Perilymph Fistula: A tear or defect in the membranes separating the middle ear from the inner ear can cause perilymph fluid to leak into the middle ear, resulting in dizziness and imbalance.

  • Post-Traumatic Vestibular Migraine (VM): TBI can trigger vestibular migraines, a type of migraine associated with vestibular symptoms. VM is characterized by vertigo, imbalance, motion sensitivity, and typical migraine headaches, often triggered by head movements or visual stimuli.

  • Chronic Subjective Dizziness (CSD)/Persistent Postural-Perceptual Dizziness (PPPD): PPPD is marked by persistent dizziness and unsteadiness, often exacerbated by complex visual environments or active movements.

  • Central Vestibular Disorders: Damage to the central vestibular pathways in the brain following TBI can lead to central vestibular and balance issues. Typical symptoms include dizziness, imbalance, coordination difficulties, and problems with vision and spatial orientation.

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Diagnosis of Dizziness

Diagnosing dizziness involves a comprehensive approach by specialists, such as vestibular physiotherapists, to identify the underlying cause of the symptoms. The diagnostic process typically includes the following steps:


  • Present and Past Medical History: The specialist will start by gathering a detailed medical history. This includes questions about the nature of the dizziness—its duration, frequency, triggers, and any associated symptoms. They will also review relevant medical conditions, current medications, recent illnesses or injuries, and lifestyle factors
  • Physical Examination: A thorough physical examination will be conducted to assess vital signs, neurological function, balance, and coordination. Specific manoeuvres may be performed to evaluate eye movements, test for nystagmus (involuntary eye movements), and assess gait and balance
  • Review of Medications: Since some medications can cause or worsen dizziness, the specialist will review the individual's current medication list. They may adjust or discontinue any medications contributing to the symptoms.
  • Vestibular Tests: Various tests will be conducted to evaluate the function of the vestibular system, including assessments of balance and spatial orientation.
  • Imaging Studies: In certain cases, imaging studies such as magnetic resonance imaging (MRI) or computed tomography (CT) scans may be helpful to exclude structural causes of dizziness in the brain or inner ear.
  • Cardiovascular Evaluation: As dizziness can sometimes be linked to cardiovascular issues, tests may be performed to assess the heart's involvement

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Treatment of Dizziness

The treatment of dizziness is guided by its underlying cause, which is identified through a comprehensive evaluation by a vestibular specialist. Common treatment options for dizziness include:


Vestibular Rehabilitation Therapy (VRT): VRT is a specialized physical therapy designed to enhance balance, reduce dizziness, and improve functional mobility in individuals with vestibular disorders. It involves exercises and manoeuvres aimed at promoting adaptation, habituation, and compensation for vestibular deficits.


Canalith Repositioning Manoeuvres: Manoeuvres like the Epley or Semont are used to treat benign paroxysmal positional vertigo (BPPV). They involve specific head and body movements to reposition displaced inner ear crystals (otoconia) and alleviate vertigo.


Medications: Medications may be prescribed to manage symptoms or address the underlying condition causing dizziness. These can include drugs to alleviate nausea and vomiting, reduce vestibular symptoms, or treat specific medical conditions. However, long-term use of vestibular medications requires caution, as they can lead to poor compensation, extrapyramidal effects, and other adverse consequences.


Lifestyle Modifications: Adjustments such as staying hydrated, optimising workstations, reducing stress, limiting caffeine and alcohol intake, and avoiding triggers can help manage dizziness and reduce symptoms.


Balance Training: Exercises designed to improve stability, coordination, and proprioception (body position awareness) may be included in a comprehensive vestibular rehabilitation program or used as standalone therapy.


Treatment of Underlying Conditions: Addressing the root causes of dizziness, such as inner ear infections, vestibular migraine, Meniere's disease, orthostatic hypotension, anxiety, or neurological disorders, is crucial for effective symptom management.


Psychological Support: Dizziness can significantly impact emotional well-being and quality of life. Psychological support, including counselling or Cognitive Vestibular Therapy, may help manage anxiety, depression, or stress related to dizziness.


Dizziness treatment should be tailored to the individual’s specific diagnosis, symptoms, functional limitations, and goals. Collaborating closely with a vestibular specialist is essential to develop a comprehensive treatment plan that addresses the individual’s needs and enhances their overall quality of life.

Galeno,E.;Pullano,E.;Mourad, F. Galeoto,G.;Frontani,F. Effectiveness of Vestibular Rehabilitation after Concussion: A Systematic Review of Randomised Controlled Trial. Healthcare  2023, 11, 90.         https://doi.org/10.3390/healthcare11010090
Aljabri, Ammar & Halawani, Alhussain & Ashqar, Alaa & Alageely, Omar & Alhazzani, Adel. (2023). The Efficacy of Vestibular Rehabilitation Therapy for Mild Traumatic Brain Injury: A Systematic Review and Meta-analysis. The Journal of head trauma rehabilitation. 10.1097/HTR.0000000000000882. 
Murray DA, Meldrum D, Lennon O
Can vestibular rehabilitation exercises help patients with concussion? A systematic review of efficacy, prescription and progression patterns
British Journal of Sports Medicine 2017;51:442-451.

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Misdiagnosis of Dizziness in TBI Patients

Dizziness is a common symptom among TBI patients but is often misdiagnosed or inadequately treated due to several factors. Addressing these challenges is essential for improving patient outcomes.


Challenges in Diagnosing Dizziness in TBI Patients


Complex Symptom Presentation: TBI patients frequently exhibit a range of overlapping symptoms, such as headaches, cognitive impairments, and emotional disturbances, which can obscure the identification of dizziness as a distinct issue. Additionally, symptoms of vestibular dysfunction may not manifest until days, weeks, or even months after the injury, potentially leading to oversight during initial evaluations.


Lack of Vestibular Clinical Training: Many frontline clinicians, including specialists, may lack in-depth training in vestibular disorders. This gap in expertise can lead to missed or incorrect diagnoses, impacting the effectiveness of treatment.


Misattribution of Symptoms: Dizziness may be mistakenly attributed to psychological factors, such as anxiety or post-traumatic stress disorder (PTSD), especially when no obvious vestibular condition is evident. Furthermore, dizziness symptoms can be misattributed to general medical or neurological issues without recognizing the specific vestibular component.


Understanding and addressing these challenges is crucial for accurate diagnosis and effective treatment of dizziness in TBI patients.

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Barriers to VRT for patients with TBI

Many TBI patients do not routinely undergo comprehensive vestibular assessment and do not receive adequate vestibular therapy, and several factors contribute to this issue. 


Traumatic Brain Injury (TBI) patients may often face challenges in expressing their vestibular symptoms to clinicians due to a combination of cognitive, communicative, and sensory factors associated with the injury. Lack of reporting can lead to inadequate care for vestibular issues. 


Both patients and healthcare professionals may lack awareness of vestibular issues in TBI and the benefits of vestibular rehabilitation therapy (VRT). This lack of awareness can result in fewer referrals and missed opportunities for effective treatment.


The shortage of specialists trained in vestibular rehabilitation can lead to delays or gaps in treatment for TBI patients experiencing dizziness. Additionally, geographic barriers can further restrict access, particularly for patients in rural or underserved areas.


The absence of standardised treatment protocols for vestibular disorders in TBI patients often results in inconsistent care and variable outcomes. Regular follow-up is crucial for adapting treatment plans and monitoring progress, yet it is frequently insufficient in the management of these disorders.


Traveling to see a specialist can significantly aggravate vestibular symptoms including travel /motion sickness in TBI patients, which may hinder their participation in treatment. 

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WHAT WE DO

Customised Vestibular Rehabilitation

Vestibular disorders are common sequelae of TBIs, affecting the inner ear and related brain structures responsible for balance control. Here are some specific vestibular disorders that we deal with in patients with TBIs
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BPPV

Benign Paroxysmal Positional Vertigo (BPPV) is a prevalent vestibular disorder marked by brief episodes of vertigo triggered by specific head movements. It results from the displacement of tiny calcium carbonate crystals (otoconia) within the inner ear’s semicircular canals. BPPV can be classified into various types, including:


  • Posterior Canalithiasis: Displacement of crystals in the posterior semicircular canal.
  • Posterior Cupulolithiasis: Crystals adhering to the cupula of the posterior canal.
  • Lateral Canalithiasis: Crystals in the lateral (horizontal) semicircular canal.
  • Lateral Cupulolithiasis: Crystals adhering to the cupula of the lateral canal.
  • Anterior Canalithiasis: Crystals in the anterior (superior) semicircular canal.
  • Apogeotropic Posterior Canalithiasis: A variant where the crystals stay in the proximal part of the posterior semicircular canal, causing atypical nystagmus that beats away from the ground when the head is in a hanging position. This presentation can be confusingly similar to the involvement of the anterior canal


Each type of BPPV requires specific diagnostic and treatment strategies to manage symptoms effectively and improve the patient’s quality of life.


For individuals with Traumatic Brain Injuries (TBIs), head trauma can dislodge these crystals, potentially leading to bilateral or mixed-type BPPV.


Many TBI patients with BPPV respond well to standard treatments like canalith repositioning manoeuvres (e.g., Epley manoeuvre). With appropriate treatment, patients often experience significant improvement or resolution of symptoms within a few sessions of treatment. However, the severity and nature of the TBI can impact BPPV prognosis. More severe brain injuries or complex TBIs may involve additional vestibular and neurological deficits, complicating the resolution of BPPV. Additionally, BPPV can recur in TBI patients, potentially more frequently or with different characteristics than in individuals without TBI. 


Monitoring and preventive strategies may be necessary.It is crucial for TBI patients experiencing dizziness or vertigo to undergo a thorough evaluation by a vestibular specialist. This evaluation will help diagnose the specific type of BPPV and differentiate it from other potential causes of symptoms. Tailoring treatment recommendations to the precise type of BPPV is essential for optimal management and recovery. 


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Vestibular Hypofunction (VHF)

Post-traumatic vestibular Hypofunction refers to the reduced or impaired function of the vestibular system following a traumatic brain injury (TBI) or head trauma. This condition can manifest as either unilateral or bilateral, depending on whether one or both sides of the vestibular system are affected. The vestibular system, located in the inner ear, is crucial for maintaining balance, spatial orientation, and stabilising gaze during head movements. When damaged by trauma, it can lead to a range of symptoms and impairments in balance and coordination.

Common symptoms of post-traumatic vestibular hypofunction include:

  • Dizziness or vertigo
  • Imbalance or unsteadiness, especially during walking or standing
  • Visual disturbances, such as blurriness or difficulty focusing
  • Nausea or motion sickness
  • Sensitivity to head movements or changes in position
  • Difficulty with spatial orientation or navigating in space


Diagnosis: Diagnosing post-traumatic vestibular hypofunction typically involves a comprehensive evaluation by a vestibular specialists, such as a vestibular physiotherapist, which may involve:

  • Medical History: Assessment of head trauma and related vestibular symptoms.
  • Physical Examination: Includes tests of balance, gait, and coordination.
  • Vestibular Function Tests: Such as the head thrust test, dynamic visual acuity test, and oscillopsia assessment.


Treatment aims to alleviate symptoms, improve balance and stability, and enhance overall functional mobility. Options may include:

  • Vestibular Rehabilitation Therapy (VRT): A specialised form of physical therapy administered by a vestibular physiotherapist that includes exercises designed to promote adaptation, habituation, and compensation for vestibular deficits.
  • Medications: While medications may be prescribed to alleviate symptoms like dizziness, nausea, or motion sickness, their long-term use should be avoided due to potential side effects such as hindering natural recovery and causing extrapyramidal symptoms.


Prognosis: The outlook for TBI patients with vestibular hypofunction is generally positive with appropriate rehabilitation, particularly when guided by a vestibular physiotherapist. However, prognosis depends on factors such as the severity of the TBI, the extent of vestibular damage, and individual patient characteristics. Early and consistent intervention, combined with a comprehensive rehabilitation program, offers the best chance for significant improvement and functional recovery. However, some patients may experience ongoing challenges requiring long-term management.

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Vestibular Migraine (VM)

Post-Traumatic Vestibular Migraine is a type of migraine that occurs after a traumatic brain injury (TBI) and is characterised by vestibular symptoms such as dizziness, vertigo, and imbalance, along with other migraine-related symptoms like photophobia, phonophobia, and aura. Notably, these vestibular symptoms may or may not be accompanied by a traditional migraine headache.

Following a TBI, the normal functioning of the vestibular system—which is critical for balance and spatial orientation—can be disrupted. This disruption may trigger vestibular symptoms, especially in individuals predisposed to migraines.


Post-traumatic vestibular migraine shares many features with typical vestibular migraine but is distinguished by its onset following head injury. Symptoms can include vertigo, dizziness, headache, visual disturbances with aura, and sensitivity to motion or visual stimuli.


Diagnosis of post-traumatic vestibular migraine involves a comprehensive evaluation by a healthcare professional, often a neurologist, headache specialist, or vestibular physiotherapist. The diagnosis is based on the individual's medical history, symptom presentation, and the exclusion of other potential causes of vestibular symptoms.


Treatment for post-traumatic vestibular migraine may include a combination of:

  • Medications: To manage symptoms and reduce the frequency and severity of migraine attacks.
  • Lifestyle Modifications: Including dietary changes, regular sleep patterns, and avoidance of migraine triggers.
  • Stress Management: Techniques such as relaxation exercises or cognitive behavioural therapy.
  • Vestibular Physiotherapy: Tailored exercises to improve balance, reduce dizziness, and enhance overall vestibular function.

Individuals with post-traumatic vestibular migraine must work closely with their vestibular specialists and vestibular physiotherapists to develop a personalised treatment plan that addresses their specific symptoms and needs. Ongoing monitoring and adjustments to the treatment plan are essential for optimising outcomes and improving quality of life
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Cognition, Memory and Psychological Issues Due to Vestibular Disorders

Vestibular disorders can significantly impact not only physical balance but also cognitive and psychological well-being. This is particularly evident in patients with Traumatic Brain Injury (TBI), where vestibular dysfunction exacerbates cognitive impairments and psychological distress. Addressing these impacts is crucial for comprehensive treatment and rehabilitation, as managing vestibular dysfunction and its cognitive and psychological consequences can greatly improve a patient’s quality of life and overall functioning.


Cognitive Impacts of Vestibular Disorders

  • Spatial Memory: The vestibular system is vital for spatial orientation and memory. Dysfunction can result in difficulties with navigation and remembering spatial layouts.
  • Short-Term Memory: Vestibular disorders can affect the hippocampus, a brain region critical for memory formation, leading to short-term memory issues.
  • Sustained Attention: TBI patients with vestibular dysfunction often struggle to maintain focus over extended periods, particularly in environments requiring continuous sensory processing.
  • Divided Attention: The ability to manage multiple tasks simultaneously is impaired, as the brain works harder to compensate for vestibular dysfunction.
  • Planning and Organization: Executive functions, such as planning, organising, and executing tasks, can be compromised by vestibular disorders.
  • Problem-Solving: Sensory processing difficulties can impair decision-making and problem-solving abilities.


Psychological Impacts of Vestibular Disorders

  • Fear of Falling: Persistent dizziness and balance issues often lead to a fear of falling, resulting in anxiety and avoidance behaviours.
  • Panic Attacks: The sensation of dizziness can trigger panic attacks, particularly in situations where patients feel vulnerable or out of control.
  • Depression: Chronic vestibular symptoms can cause feelings of hopelessness and helplessness, contributing to depression.
  • Social Isolation: Avoidance of social activities due to fear of symptoms can lead to loneliness and depression.
  • Cognitive Load: The brain's efforts to compensate for vestibular deficits can lead to mental fatigue and increased stress.
  • Sleep Disturbances: Anxiety and physical discomfort from vestibular issues can disrupt sleep, further exacerbating cognitive and psychological impairments.


Interdisciplinary Approach

  • Vestibular Rehabilitation Therapy (VRT): Vestibular physiotherapists focus on improving vestibular function and compensation through tailored exercises.
  • Cognitive Rehabilitation: Techniques to enhance memory, attention, and executive functions.
  • Psychological Support: Counselling and therapy to manage anxiety, depression, and other emotional challenges.
  • Lifestyle Modifications: Modifying the home and work environment, regular physical activity and social engagement.


By integrating these approaches, vestibular physiotherapists and other healthcare professionals can significantly improve the quality of life for TBI patients dealing with vestibular disorders, helping them regain functional independence and emotional stability.

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PPPD


PPPD in TBIs

Individuals who have sustained a TBI, due to the disruption of sensory input and integration processes in the brain following a TBI can contribute to the development or exacerbation of symptoms characteristic of PPPD.

The hallmark symptoms of PPPD include persistent feelings of dizziness, unsteadiness, and visual disturbances, often described as feeling "off balance" or "rocking" sensations. These symptoms may be accompanied by a heightened sensitivity to motion, visual stimuli, and busy environments. Individuals with PPPD may also experience symptoms such as anxiety, fatigue, difficulty concentrating, and avoidance of activities that trigger or exacerbate symptoms.

Diagnosis

Diagnosing PPPD in individuals with TBIs involves a comprehensive evaluation by a trained vestibular specialist such as a vestibular specialist. The diagnosis is based on the presence of characteristic symptoms, a history of TBI or head trauma, and the exclusion of other potential causes of dizziness and imbalance.

Treatment

Treatment for PPPD focuses on symptom management, functional improvement, and enhancing the quality of life. Treatment options may include:

Vestibular rehabilitation therapy (VRT): A specialized form of physical therapy that includes exercises and manoeuvers to improve balance, stability, and adaptation to vestibular stimuli.

Cognitive-behavioural therapy (CBT): Therapy techniques aimed at addressing anxiety, maladaptive beliefs, and avoidance behaviours associated with PPPD.

Medications: Medications may be prescribed to manage symptoms such as anxiety, depression, or migraine headaches that commonly coexist with PPPD.

Lifestyle modifications: Strategies to optimize sleep, manage stress, and minimize triggers that exacerbate symptoms, such as avoiding excessive visual stimulation or prolonged periods of upright posture.

Prognosis: The prognosis for individuals with PPPD following TBIs varies depending on the severity of symptoms, response to treatment, and individual factors such as age, overall health, and the presence of coexisting conditions. While some individuals may experience significant improvement with appropriate management and rehabilitation, others may have persistent symptoms that require ongoing symptom management and support.

Overall, managing PPPD in individuals with TBIs requires a multidisciplinary approach, with treatment tailored to the individual's specific symptoms, functional limitations, and goals. Collaboration between clinicians, including vestibular physiotherapist, psychologists, and other specialists, is essential for optimising outcomes and improving quality of life for individuals living with PPPD following TBIs

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Visual Vertigo

Visual vertigo, also known as visually induced dizziness, is characterized by symptoms of dizziness, vertigo, and imbalance that are triggered or worsened by specific visual stimuli or environments. Individuals with visual vertigo may experience disorientation, lightheadedness, nausea, and a sensation of swaying or rocking when exposed to visually complex, moving, or disorienting stimuli.

Triggers

Visual vertigo is typically triggered by visual stimuli or situations that challenge the brain's ability to process visual information and maintain spatial orientation. Common triggers include:

  • Busy or Crowded Environments: Such as shopping malls or airports.
  • Visual Motion: Like scrolling on a computer screen, watching movies, or using a smartphone.
  • Patterned or Visually Complex Environments: For example, busy wallpaper or striped carpets.
  • Fast-moving or Rapidly Changing Visual Stimuli: Such as driving or riding in a car.

Visual vertigo often coexists with vestibular disorders like benign paroxysmal positional vertigo (BPPV), vestibular migraine, or vestibular hypofunction. In these cases, visual vertigo may represent a manifestation of the underlying vestibular dysfunction, with visual stimuli triggering or exacerbating vestibular symptoms.

Diagnosis

Diagnosing visual vertigo involves a comprehensive evaluation by a vestibular specialist or vestibular physiotherapist. The diagnosis is based on characteristic symptoms, a thorough medical history, a physical examination, and the exclusion of other potential causes of dizziness and imbalance.

Treatment

Treatment for visual vertigo focuses on managing symptoms, improving function, and reducing sensitivity to visual triggers. Options may include:

  • Vestibular Rehabilitation Therapy (VRT): Exercises and manoeuvres aimed at improving adaptation to visual stimuli and enhancing balance and stability.
  • Cognitive-Behavioural Therapy (CBT): Techniques to address anxiety, avoidance behaviours, and maladaptive beliefs associated with visual vertigo.
  • Lifestyle Modifications: Strategies to minimize exposure to visual triggers, optimize environmental conditions, and reduce stress and anxiety.

Managing visual vertigo requires a multidisciplinary approach. Treatment should be tailored to the individual's specific symptoms, triggers, and functional limitations. Collaboration between healthcare providers, including neurologists, vestibular physiotherapists, psychologists, and other specialists, is essential for optimising outcomes and improving the quality of life for individuals with visual vertigo.

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Cervicogenic Dizziness

Cervicogenic dizziness refers to dizziness that arises from dysfunction in the cervical spine/neck. It is characterized by symptoms of dizziness, unsteadiness, or imbalance that are believed to be related to cervical musculoskeletal disorders, such as neck pain, cervical joint dysfunction, or cervical spine pathology. Cervicogenic dizziness can occur following traumatic brain injuries (TBIs) and may contribute to or exacerbate symptoms of vestibular dizziness and imbalance.

Here are some key points about cervicogenic dizziness in the context of traumatic brain injuries:


Cervicogenic dizziness symptoms

             Dizziness or vertigo, swaying, or unsteadiness.

             Neck pain or stiffness typically localized to the cervical spine.

             Headaches, particularly originating from the base of the skull or neck.

             Visual disturbances, such as blurred vision or difficulty focusing

             Sensitivity to head movements or changes in neck position


Diagnosis 

Diagnosing cervicogenic dizziness in individuals with TBIs involves a comprehensive evaluation by a Musculoskeletal vestibular specialist. The diagnosis is based on the presence of characteristic symptoms, a history of TBI or head trauma, and clinical findings suggestive of cervical spine dysfunction, such as restricted range of motion or tenderness to palpation in the neck.


Treatment

Treatment for cervicogenic dizziness aims to address underlying cervical spine dysfunction, alleviate symptoms, and improve functional outcomes. Treatment options may include:

    • Manual therapy: Techniques such as spinal manipulation, mobilization, or soft tissue massage to restore joint mobility and reduce muscle tension in the cervical spine.
    • Exercise therapy: Specific exercises and stretches to improve cervical spine strength, flexibility, and posture, as well as proprioceptive training to enhance sensory integration and balance.
    • Postural and ergonomic modifications: Education on proper posture, body mechanics, and ergonomic principles to minimize strain on the cervical spine and reduce symptoms.
    • Medications: Medications such as muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), or analgesics may be prescribed to manage neck pain and associated symptoms.

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Multi-Sensory Balance Dysfunction

Balance control is a complex process that relies on the integration of sensory inputs from multiple systems: vestibular, visual, and somatosensory.

Multi-Sensory Balance Control

  • Vestibular System: Detects head movements and spatial orientation.
  • Visual System: Provides environmental and spatial orientation information.
  • Somatosensory System: Offers feedback on body position and movement through proprioception.
  • Central Vestibular System: Integrates multisensory balance signals.

In individuals with Traumatic Brain Injury (TBI), this integration is often disrupted, leading to significant balance and coordination problems. Understanding the mechanisms of multi-sensory balance control and the impact of TBI is essential for developing effective rehabilitation strategies.

Effective management of multi-sensory balance issues in TBI patients requires a comprehensive approach that addresses the complex interplay between various sensory systems. By utilising specialised assessments and tailored rehabilitation strategies, vestibular physiotherapists can help TBI patients regain better balance control and improve their overall quality of life.

Vestibular rehabilitation therapy (VRT) is a vital component in the management of multi-sensory balance issues in TBI patients. By providing a structured and individualised approach, VRT can significantly improve balance, reduce dizziness, and enhance overall quality of life. Through comprehensive assessment, tailored exercises, and continuous support, vestibular physiotherapists play a crucial role in helping TBI patients regain their functional independence and confidence.

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